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de Marco G, Valaikaite R, Chargui M, Coulin B, Vazquez O, Tabard-Fougère A, Steiger CN, Dayer R, Ceroni D. Femoral fractures and abuse in children under 36 months old: a Swiss case series. J Pediatr Orthop B 2024; 33:452-461. [PMID: 37909866 PMCID: PMC11288394 DOI: 10.1097/bpb.0000000000001140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 09/17/2023] [Indexed: 11/03/2023]
Abstract
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.
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Affiliation(s)
- Giacomo de Marco
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Raimonda Valaikaite
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Moez Chargui
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Benoit Coulin
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Oscar Vazquez
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Anne Tabard-Fougère
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Christina N. Steiger
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Romain Dayer
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Dimitri Ceroni
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
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Mohammad Moawad A, Mohamed Ibraheim Moawad E, Ali Mohamed Mahrous M, Zein MM, Salama Mahmoud Mahmoud A. Pediatric skeletal injuries in emergency department; an alarm of child maltreatment in Egypt: A cross-sectional study. Leg Med (Tokyo) 2024; 70:102471. [PMID: 38876000 DOI: 10.1016/j.legalmed.2024.102471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 05/27/2024] [Accepted: 06/09/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Child physical abuse, a type of child maltreatment (CM), poses a significant global public health concern. Nonaccidental fractures and soft tissue injuries, which encompass any action that directly or indirectly harms a child, are the primary indicators of physical abuse in children. OBJECTIVE This study aimed to investigate the prevalence, risk factors, and outcomes of accidental and nonaccidental skeletal fractures in a sample of Egyptian children. METHODS A cross-sectional analytical study was conducted between March 2022 and August 2022. A total of 156 children who presented with skeletal injuries and attended Mobarak Central Hospital were enrolled. Patients were subjected to full history taking, complete examination, and investigations. A structured questionnaire was administered to all the legal guardians. RESULTS Physical abuse was reported in 22.4 % of cases, while medical neglect was reported in 19.9 % of cases. The incidence of physical abuse was notably higher among children whose fathers were smokers and/or drug addicts (p ≤ 0.05). The most common form of physical abuse was hitting (94.3 %). Among skeletal injuries, fractures were predominant (94.3 %), primarily closed fractures associated with contusions. Fractures of the upper limb accounted for the highest incidence (94.3 %) of skeletal injuries, and 60 % of physically abused children experienced moderate-severity injuries. CONCLUSION The most common fracture observed in abused children is the upper limb fracture, typically involving a single bone. Clinicians should be more vigilant in suspecting abuse, even in cases where there is an isolated fracture, and advocate for the development of parental training programs.
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Affiliation(s)
- Asmaa Mohammad Moawad
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Cairo University, Kasr Alainy Street, Cairo 11562, Egypt.
| | | | - Mohamed Ali Mohamed Mahrous
- Specialist of Orthopedic Surgery, Mubarak El Markazy Hospital, Ministry of Health, Kasr Alainy Street, Cairo 11562, Egypt
| | - Marwa M Zein
- Department of Public Health and Community Medicine, Faculty of Medicine, Cairo University, Kasr Alainy Street, Cairo 11562, Egypt.
| | - Amal Salama Mahmoud Mahmoud
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Cairo University, Kasr Alainy Street, Cairo 11562, Egypt.
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Hauschild MH, Omar HN, Bauer M, Sarkisova N, Lee CJ, Wren TAL, Goldstein RY. Investigating the Determinants of Nonaccidental Trauma Evaluation in Pediatric Femur Fractures. J Am Acad Orthop Surg 2024:00124635-990000000-01042. [PMID: 39018661 DOI: 10.5435/jaaos-d-24-00198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/27/2024] [Indexed: 07/19/2024] Open
Abstract
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.
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Affiliation(s)
- Maia H Hauschild
- From the Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA
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Burkow J, Holste G, Otjen J, Perez F, Junewick J, Zbojniewicz A, Romberg E, Menashe S, Frost J, Alessio A. High sensitivity methods for automated rib fracture detection in pediatric radiographs. Sci Rep 2024; 14:8372. [PMID: 38600311 PMCID: PMC11006902 DOI: 10.1038/s41598-024-59077-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 04/07/2024] [Indexed: 04/12/2024] Open
Abstract
Rib fractures are highly predictive of non-accidental trauma in children under 3 years old. Rib fracture detection in pediatric radiographs is challenging because fractures can be obliquely oriented to the imaging detector, obfuscated by other structures, incomplete, and non-displaced. Prior studies have shown up to two-thirds of rib fractures may be missed during initial interpretation. In this paper, we implemented methods for improving the sensitivity (i.e. recall) performance for detecting and localizing rib fractures in pediatric chest radiographs to help augment performance of radiology interpretation. These methods adapted two convolutional neural network (CNN) architectures, RetinaNet and YOLOv5, and our previously proposed decision scheme, "avalanche decision", that dynamically reduces the acceptance threshold for proposed regions in each image. Additionally, we present contributions of using multiple image pre-processing and model ensembling techniques. Using a custom dataset of 1109 pediatric chest radiographs manually labeled by seven pediatric radiologists, we performed 10-fold cross-validation and reported detection performance using several metrics, including F2 score which summarizes precision and recall for high-sensitivity tasks. Our best performing model used three ensembled YOLOv5 models with varied input processing and an avalanche decision scheme, achieving an F2 score of 0.725 ± 0.012. Expert inter-reader performance yielded an F2 score of 0.732. Results demonstrate that our combination of sensitivity-driving methods provides object detector performance approaching the capabilities of expert human readers, suggesting that these methods may provide a viable approach to identify all rib fractures.
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Affiliation(s)
| | | | | | | | - Joseph Junewick
- Michigan State University, East Lansing, MI, 48823, USA
- Helen DeVos Children's Hospital, Grand Rapids, MI, USA
- Advanced Radiology Services, Grand Rapids, MI, USA
| | - Andy Zbojniewicz
- Michigan State University, East Lansing, MI, 48823, USA
- Helen DeVos Children's Hospital, Grand Rapids, MI, USA
- Advanced Radiology Services, Grand Rapids, MI, USA
| | | | | | - Jamie Frost
- Michigan State University, East Lansing, MI, 48823, USA
- Helen DeVos Children's Hospital, Grand Rapids, MI, USA
- Advanced Radiology Services, Grand Rapids, MI, USA
| | - Adam Alessio
- Michigan State University, East Lansing, MI, 48823, USA.
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Schermerhorn SMV, Muensterer OJ, Ignacio RC. Identification and Evaluation of Non-Accidental Trauma in the Pediatric Population: A Clinical Review. CHILDREN (BASEL, SWITZERLAND) 2024; 11:413. [PMID: 38671630 PMCID: PMC11049109 DOI: 10.3390/children11040413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024]
Abstract
Non-accidental trauma (NAT) is a major cause of morbidity and mortality for children around the world and most significantly impacts children under one year of age. Prompt and comprehensive treatment of these children relies on a high index of suspicion from any medical provider that treats pediatric patients. This review discusses those most at risk for experiencing NAT, and common initial presentations, to assist providers in the identification of potential victims. In addition, this review provides guidance on the recommended workup for these patients so that the full extent of associated injuries may be identified and the appropriate healthcare team may be assembled.
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Affiliation(s)
| | - Oliver J. Muensterer
- LMU Medical Center, Pediatric Surgery, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians-University, Lindwurmstrasse 4, 80337 Munich, Germany;
| | - Romeo C. Ignacio
- Department of Surgery, UCSD School of Medicine, 9500 Gilman Dr, La Jolla, CA 92093, USA
- Division of Pediatric Surgery, Rady Children’s Hospital San Diego, 3020 Children’s Way, San Diego, CA 92123, USA
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Waite E, Ahmed Z. How safe and effective are paediatric virtual fracture clinics? A systematic review. Front Digit Health 2023; 5:1261035. [PMID: 37964895 PMCID: PMC10641786 DOI: 10.3389/fdgth.2023.1261035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
Introduction Virtual fracture clinics (VFC) involve a consultant-led multidisciplinary team meeting where cases are reviewed before a telephone consultation with the patient. VFCs have the advantages of reducing waiting times, outpatient appointments and time off school compared to face-to-face (F2F) fracture clinics. There has been a surge in VFC use since the COVID-19 pandemic but there are still concerns over safety in the paediatric population. Fractures make up a large burden of paediatric injuries, therefore research is required on the safety and efficacy of paediatric VFCs. This systematic review will look at the safety and effectiveness of paediatric VFCs, as well as determine the cost-effectiveness and parent preferences. Methods As per the PRISMA guidelines two independent reviewers searched the following databases: Medline, Embase and Web of Science. Studies were included if children under 18 years old presented to A&E with a suspected or confirmed simple un-displaced fracture and were referred to a VFC. The primary outcomes assessed were effectiveness and safety, with the secondary outcomes of cost-effectiveness and parent satisfaction. Results Six studies met the inclusion criteria for this systematic review. There was a high rate of direct discharge from the VFC leading to reduced outpatient appointments. All patients were seen within 72 h of presentation. There were limited incidences of missed fractures and the rates of re-presentation were similar to that of F2F orthopaedic clinics. There were significant cost savings for the hospitals and high parent satisfaction. Discussion VFCs have shown to be safe and effective at managing most stable, low operative risk paediatric fractures. Safety must be ensured with a telephone helpline and an open return to fracture clinic policy. More research is needed into specific paediatric fracture types to be managed in the VFC. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/#searchadvanced, identifier: CRD42023423795.
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Affiliation(s)
- Emma Waite
- College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
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Al-Hajj S, Farran SH, Dekmak B, Hneiny L, Abou Abbas H, Hassoun A, Youness N, Ghalayini S, Abou Khalil N, Lecky F, Shahjouieh S, Ghamlouche L, Nasrallah Z, Kobeissy F. Pediatric Traumatic Brain Injury in the Middle East and North Africa Region: A Systematic Review and Meta-Analysis to Assess Characteristics, Mechanisms, and Risk Factors. Neurotrauma Rep 2023; 4:693-714. [PMID: 37908319 PMCID: PMC10615069 DOI: 10.1089/neur.2023.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023] Open
Abstract
Pediatric traumatic brain injury (pTBI) represents a major cause of child injuries in the Middle East and North Africa (MENA) region. This review aims to assess pTBIs in the MENA region and reports their clinical severity and outcomes. A search was conducted using major electronic databases, including Medline/Ovid, PubMed, EMBASE, Web of Science, and SCOPUS. Abstracts were screened independently and in duplicate to detect original research. The objective and study findings for each article were recorded, along with the mechanism of pTBI, patient age and sex, injury assessment tool(s) used, and outcome. A total of 1345 articles were retrieved, of which 152 met the criteria for full-text review, and 32 were included in this review. Males predominantly suffered from pTBIs (78%). Motor vehicle accidents, followed by child abuse, were the leading causes of pTBI. Overall, 0.39% of cases were mild, 0.58% moderate, 16.25% severe, and 82.27% unclassified. The mortality rate was 13.11%. Most studies used the computed tomography scan, Glasgow Coma Scale, Abbreviated Injury Scale, and Injury Severity Score as investigation methods. This review reports on the alarming rate of child-abuse-related pTBI and offers further understanding of pTBI-associated risk factors and insight into the development of strategies to reduce their occurrence, as well as policies to promote child well-being.
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Affiliation(s)
- Samar Al-Hajj
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Sarah H. Farran
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Batoul Dekmak
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Layal Hneiny
- Saab Medical Library, American University of Beirut, Beirut, Lebanon
| | - Hussein Abou Abbas
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Aya Hassoun
- School of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Nadine Youness
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Sarah Ghalayini
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Nour Abou Khalil
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, University of Sheffield, Sheffield, United Kingdom
| | - Shima Shahjouieh
- Department of Neurosurgery, University of New Mexico, New Mexico
| | - Layal Ghamlouche
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Zainab Nasrallah
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Firas Kobeissy
- Department of Biochemistry and Molecular Biology Faculty of Medicine, American University of Beirut, Beirut, Lebanon
- Department of Neurobiology, Center for Neurotrauma, Multiomics & Biomarkers (CNMB), Neuroscience Institute, Morehouse School of Medicine, Atlanta, Georgia, USA
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Muhammad U, Di Bella C, Thompson S, Istfan S. Skeletal Surveys in Suspected Non-accidental Trauma: Examining the Yield and Current Clinical Practices at a Regional Referral Center in West Virginia. Cureus 2023; 15:e46020. [PMID: 37900491 PMCID: PMC10602595 DOI: 10.7759/cureus.46020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction Non-accidental trauma (NAT) is a leading cause of pediatric injury and death. When NAT is suspected in children under the age of 24 months, the American Academy of Pediatrics (AAP) recommends using skeletal surveys (SS) to identify acute, healing, or old fractures and to repeat the SS approximately two weeks after initial imaging as acute fractures can sometimes not be seen on initial imaging. In this study, we determined the yield of initial and follow-up SS obtained for suspected NAT in children under the age of 24 months at a regional referral hospital. Methods We reviewed charts of children younger than 24 months who received SS imaging, due to physical abuse suspicion, at our hospital system between 2017 and 2022. We used convenient sampling to examine all SS occurring at the Charleston Area Medical Center Healthcare System. Results A total of 61 of the 126 initial SS showed fractures. Only 9% of children received follow-up SS. Repeat SS performed approximately two weeks after positive initial SS showed signs of healing, including new fractures not reported on the initial scan. Follow-up SS performed within eight weeks after initial negative scans continued to be negative. Lastly, consults from child abuse pediatricians were found to be underutilized as only 48% of patients received consultations. Conclusion Follow-up SS and child abuse pediatrician consults were found to be underutilized. Follow-up SS and consulting child abuse specialists should not be overlooked, irrespective of positive or negative initial SS, to provide optimal management of NAT.
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Affiliation(s)
- Umer Muhammad
- Pediatrics, Charleston Area Medical Center, Charleston, USA
| | - Claire Di Bella
- Pediatrics, West Virginia University School of Medicine, Charleston, USA
| | - Stephanie Thompson
- Institute of Academic Medicine, Charleston Area Medical Center, Charleston, USA
| | - Sharon Istfan
- Pediatrics, Charleston Area Medical Center, Charleston, USA
- Pediatric Hospital Medicine, Vanderbilt University, Nashville, USA
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Baab SM, Lawsing JF, Macalino CS, Springer JH, Cline DM. Nonaccidental Pediatric Trauma: Which Traditional Clues Predict Abuse? Pediatr Emerg Care 2023; 39:641-645. [PMID: 37463155 DOI: 10.1097/pec.0000000000003012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
OBJECTIVES The objective of this study is to determine which of the child abuse clues quoted in the literature predict nonaccidental trauma (NAT): history incongruent with injuries found on examination or imaging, old injuries present, history of trauma denied by caregivers, multiple fractures present, changing history, fractures of varied duration, metaphyseal fracture, ear bruise, neck bruise, different history (second historian), and metaphyseal fracture. METHODS This is a 4-year retrospective study of all suspected NAT cases referred to our medical center. In addition to the index visit, medical records were searched for visits before the index visit with patient historical or physical findings that might have suggested NAT but were not investigated. The association of diagnostic clues and the outcome were assessed by chi-square and logistic regression analysis. RESULTS For 48 months, there were 109 cases of suspected NAT referred for evaluation (age range, 1 week to 15 years). After formal investigation by an abuse specialist, 79.3% of the cases were considered "likely abuse". Those historical or physical findings with a univariate association with a final conclusion of likely abuse included history incongruent with injuries, old injuries present, trauma history denied, changed history, and retinal hemorrhage. In multivariate logistic regression, only a history incongruent with injures remained an independent predictor of likely abuse (odds ratio, 8.65; 95% confidence interval, 1.74-43.07; P = 0.0151). After review of prior records, in only 2 of 109 cases (1.8%) was there a prior visit where NAT could have been suspected; however, history was thought to be congruent with the injury at the original visits. CONCLUSION In this 4-year study of NAT, the clinical clue that best predicted likely abuse after expert investigation was a history that was incongruent with the injuries found on emergency department evaluation. The incidence of possible early recognition from a prior emergency department visit in this group was very low, <2% of cases.
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10
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Holdroyd I, Barton G, Holdroyd D. The effect of working tax credits on child maltreatment rates: A systematic review. CHILD ABUSE & NEGLECT 2023; 143:106279. [PMID: 37331186 DOI: 10.1016/j.chiabu.2023.106279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 05/15/2023] [Accepted: 06/04/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND Socioeconomic status and poverty are strongly associated with Child Maltreatment. Multiple studies have described the effects of working tax credits on Child Maltreatment with heterogeneous results. There is yet to be a comprehensive review of this research. OBJECTIVES This study aims to review all research which explores the effect of working tax credits on child maltreatment. METHODS Three databases (Ovid Medline, Scopus and Web of Science) were searched. Title and abstracts were screened according to a set of eligibility criteria. Data were extracted from eligible studies, and risk of bias was assessed using the Risk of Bias in Non-randomized Studies of Interventions tool. Results were synthesised narratively. RESULTS Nine studies were included. Of these, five papers investigated overall reports of child maltreatment, with three finding a positive effect of tax credits. Results suggested a protective effect against child neglect, however, no significant effect was found with respect to physical or emotional abuse. Three of four papers found that working tax credits resulted in decreased rates of entry to foster care. Mixed results were found with respect to self-reported child protective services contact. A range of methodological and temporal differences between studies was identified. CONCLUSIONS Overall, some evidence found that in work tax credits are protective against child maltreatment and that they are most effective in reducing neglect. Policymakers can take courage in these results, as they represent an example whereby the "risk factors" of child maltreatment can be countered in order to reduce rates of it.
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Affiliation(s)
- Ian Holdroyd
- School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SP, UK.
| | - George Barton
- School of Medical Education, Newcastle University, Newcastle, UK
| | - David Holdroyd
- School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SP, UK
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11
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Fernando UPM, Pranavan S, Hameed S, Munasinghe BM. Bone pathology mimicking non-accidental injury in a child - Bewildered by bones, case report and review of the literature. Int J Surg Case Rep 2023; 108:108393. [PMID: 37311325 DOI: 10.1016/j.ijscr.2023.108393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 06/15/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Physical abuse of children is criminal conduct in the purview of medico-legal sciences and the confirmative diagnosis of 'child abuse' is imperative for further legal proceedings. Clinicians play a pivotal role in the protection of children by recognizing and reporting such cases and treating the victims of abuse. PRESENTATION OF CASE To the best of our knowledge, we present the first case report in literature where osteofibrous dysplasia resulted in a pathological fracture in a 10-month-old South-Asian child which resembled the picture of child abuse. CLINICAL DISCUSSION The challenges faced by clinicians in the process of analysis of presumed child abuse are numerous and careful formulation and elimination of medical conditions which may mimic non-accidental injury (NAI) is a must, prior to making an incontrovertible diagnosis. CONCLUSION The telltale signs of NAI such as soft tissue injuries and fractures in a victimized child should always be evaluated cautiously with the intent of excluding pathologies that may mimic them and the evidence in this regard is seldom in literature.
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Affiliation(s)
- U P M Fernando
- Medical Officer in National Blood Transfusion Service, Ministry of Health, Sri Lanka
| | - S Pranavan
- Consultant Forensic Pathologist, Ministry of Health, Sri Lanka
| | - S Hameed
- Consultant Orthopaedic Surgeon, Ministry of Health, Sri Lanka
| | - B M Munasinghe
- Specialty Registrar in Anaesthetics, Department of Anaesthesiology and Intensive Care, Queen Elizabeth the Queen Mother Hospital, Margate, UK.
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12
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Macorano E, Gentile M, Stellacci G, Manzionna M, Mele F, Calvano M, Leonardelli M, Duma S, De Gabriele G, Cristalli A, Minella R, Di Fazio A, Introna F. 'Compressed Baby Head': A New 'Abusive Head Trauma' Entity? CHILDREN (BASEL, SWITZERLAND) 2023; 10:1003. [PMID: 37371236 DOI: 10.3390/children10061003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Child abuse represents an important issue in the medico-legal and social context. In the last few decades, various aspects and mechanisms have been identified in child abuse case studies; however, constant research is needed in the field. With this paper, the authors will present a case of a new entity of Abusive Head Trauma that has come to the attention of medico-legal experts. DISCUSSION The trauma analysis performed on the cranio-encephalic district of the baby revealed quite peculiar lesions that led the authors to exclude that the injuries had been solely caused by violent shaking of the baby's head, as suggested by Shaken Baby Syndrome. Instead, the authors hypothesised that another lesion mechanism had been added to this one, namely latero-lateral cranial compression. The comprehensive and exhaustive analysis of the case led the authors to present a new possible entity in child abuse trauma, namely 'Compressed Baby Head'. CONCLUSIONS To the best of our knowledge, in the current literature, no similar clinical cases have ever been described. Thus, the case's uniqueness deserves to be brought to the attention of experts and the entire scientific community, as well as medical personnel, paediatricians, and reanimators. These professional figures are the first individuals who may encounter complex clinical cases such as the one presented in this paper; thus, they need to know how to properly manage the case and ensure protection for the abused infants and children.
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Affiliation(s)
- Enrica Macorano
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Mattia Gentile
- Medical Genetics, Maternal and Child Department, Hospital of Venus, 70012 Bari, Italy
| | | | - Mariano Manzionna
- Complex Operating Unit, Paediatric and Neonatology, San Paolo Hospital, ASL Bari, 70100 Bari, Italy
| | - Federica Mele
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Mariagrazia Calvano
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Mirko Leonardelli
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Stefano Duma
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Giovanni De Gabriele
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Alessandro Cristalli
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Raffaella Minella
- School of Biological and Environmental Sciences, Liverpool John Moores University, Liverpool L3 5UX, UK
| | - Aldo Di Fazio
- Regional Complex Intercompany Institute of Legal Medicine, 85100 Potenza, Italy
| | - Francesco Introna
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
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13
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Ruiz-Maldonado TM, Alsanea Y, Coats B. Age-related skull fracture patterns in infants after low-height falls. Pediatr Res 2023; 93:1990-1998. [PMID: 36289313 PMCID: PMC10523413 DOI: 10.1038/s41390-022-02345-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/17/2022] [Accepted: 09/25/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Prior research and experience has increased physician understanding of infant skull fracture prediction. However, patterns related to fracture length, nonlinearity, and features of complexity remain poorly understood, and differences across infant age groups have not been previously explored. METHODS To determine how infant and low-height fall characteristics influence fracture patterns, we collected data from 231 head CT 3D reconstructions and quantified length and nonlinearity using a custom image processing code. Regression analysis was used to determine the effects of age and fall characteristics on nonlinearity, length, and features of fracture complexity. RESULTS While impact surface had an important role in the number of cracks present in a fracture, younger infants and greater fall heights significantly affected most features of fracture complexity, including suture-to-suture spanning and biparietal involvement. In addition, increasing fracture length with increasing fall height supports trends identified by prior finite-element modeling. Finally, this study yielded results supporting the presence of soft tissue swelling as a function of fracture location rather than impact site. CONCLUSIONS Age-related properties of the infant skull confer unique fracture patterns following head impact. Further characterization of these properties, particularly in infants <4 months of age, will improve our understanding of the infant skull's response to trauma. IMPACT Younger infant age and greater fall heights have significant effects on many features of fracture complexity resulting from low-height falls. Incorporating multiple crack formation and multiple bone involvement into computational models of young infant skull fractures may result in increased biofidelity. Drivers of skull fracture complexity are not well understood, and skull fracture patterns in real-world data across infant age groups have not been previously described. Understanding fracture complexity relative to age in accidental falls will improve the understanding of accidental and abusive head trauma.
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Affiliation(s)
| | - Yousef Alsanea
- Department of Mechanical Engineering, University of Utah, Salt Lake City, UT, USA
| | - Brittany Coats
- Department of Mechanical Engineering, University of Utah, Salt Lake City, UT, USA
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14
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O'Hara MA, Valvano TJ, Kashyap M, Daly JC, Bachim AN, Care MM, Egge MK, Kondis JS, Lenane AM, Maddocks ABR, Metz JB, Nielsen AK, Reeder KN, Ruda MT, Segal R, Sugarman JM, Weeks K, Oral R. Understanding Bilateral Skull Fractures in Infancy: A Retrospective Multicenter Case Review. Pediatr Emerg Care 2023; 39:329-334. [PMID: 35413039 DOI: 10.1097/pec.0000000000002704] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bilateral skull fractures in infancy often raise suspicion for abuse. Nevertheless, literature suggests that they may occur accidentally. However, empiric data are lacking. OBJECTIVE This multicenter retrospective review aimed to characterize bilateral skull fractures in a large sample. PARTICIPANTS AND SETTING Medical records for infants younger than 24 months with bilateral skull fractures involving hospital consultation with a child abuse pediatrician (CAP) were reviewed from 2005 to 2020 at 13 nationally represented institutions. METHODS Standardized data collection across institutions included historical features, fracture characteristics, and additional injuries, as well as the CAP's determination of accident versus abuse. Pooled data were analyzed for descriptive and bivariate analyses. RESULTS For 235 cases, 141 were accidental, and 94 abuse. The majority occurred in young infants, and a history of a fall was common in 70% of cases. More than 80% involved both parietal bones. Bilateral simple linear fractures were more common in accidental cases, 79% versus 35%, whereas a complex fracture was more frequent in abuse cases, 55% versus 21% ( P < 0.001). Almost two thirds of accidental cases showed approximation of the fractures at the sagittal suture, compared with one third of abuse cases ( P < 0.001). Whereas focal intracranial hemorrhage was seen in 43% of all cases, diffuse intracranial hemorrhage was seen more in abuse cases (45%) than accidents (11%). Skin trauma was more common in abusive than accidental injury (67% vs 17%, P < 0.001), as were additional fractures on skeletal survey (49% vs 3%, P < 0.001). CONCLUSIONS A fall history was common in bilateral skull fractures deemed accidental by a CAP. Most accidental cases involved young infants with biparietal simple linear fractures, without skin trauma or additional fractures. A skeletal survey may aid in the determination of accidental or abusive injury for unwitnessed events resulting in bilateral skull fractures in infants.
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Affiliation(s)
| | - Thomas J Valvano
- Department of Pediatrics, Oregon Health and Science University, Portland, OR
| | - Marisha Kashyap
- Mailman School of Public Health, Columbia University, New York, NY
| | - Jennie C Daly
- Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Angela N Bachim
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Marguerite M Care
- Department of Radiology and Medical Imaging, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Melissa K Egge
- Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Jamie S Kondis
- Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO
| | - Ann M Lenane
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY
| | - Alexis B R Maddocks
- Department of Radiology, New York-Presbyterian Hospital, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
| | - James B Metz
- Department of Pediatrics, University of Vermont Children's Hospital, Burlington, VT
| | - Anne K Nielsen
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA
| | - Kristen N Reeder
- Department of Pediatrics, UT Southwestern Medical Center, Dallas
| | - Michelle T Ruda
- Department of Pediatrics, University of Texas Health Science Center, Houston, TX
| | - Rachel Segal
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA
| | - Jacqueline M Sugarman
- Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY
| | - Kerri Weeks
- Department of Pediatrics, Wesley Children's Hospital, Wichita, KS
| | - Resmiye Oral
- Department of Pediatrics, Children's Hospital at Dartmouth, Lebanon, NH
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15
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Biswas A, Krishnan P, Albalkhi I, Mankad K, Shroff M. Imaging of Abusive Head Trauma in Children. Neuroimaging Clin N Am 2023; 33:357-373. [PMID: 36965952 DOI: 10.1016/j.nic.2023.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
In this article, we describe relevant anatomy, mechanisms of injury, and imaging findings of abusive head trauma (AHT). We also briefly address certain mimics of AHT, controversies, pearls, and pitfalls. Concepts of injury, its evolution, and complex nature of certain cases are highlighted with the help of case vignettes.
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Affiliation(s)
- Asthik Biswas
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada; Department of Medical Imaging, University of Toronto, Ontario, Canada; Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N3JH, UK.
| | - Pradeep Krishnan
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada; Department of Medical Imaging, University of Toronto, Ontario, Canada
| | - Ibrahem Albalkhi
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N3JH, UK; College of Medicine, Alfaisal University, Al Takhassousi، Al Zahrawi Street interconnecting with, Riyadh 11533, Saudi Arabia
| | - Kshitij Mankad
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N3JH, UK; UCL GOS Institute of Child Health
| | - Manohar Shroff
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada; Department of Medical Imaging, University of Toronto, Ontario, Canada
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16
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Paddock M, Choudhary AK, Jeanes A, Mankad K, Mannes I, Raissaki M, Adamsbaum C, Argyropoulou MI, van Rijn RR, Offiah AC. Controversial aspects of imaging in child abuse: a second roundtable discussion from the ESPR child abuse taskforce. Pediatr Radiol 2023; 53:739-751. [PMID: 36879046 PMCID: PMC10027646 DOI: 10.1007/s00247-023-05618-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 03/08/2023]
Abstract
This second roundtable discussion was convened at the 56th European Society of Paediatric Radiology (ESPR) 2022 Annual Meeting in Marseille, France, to discuss controversial aspects of imaging in child abuse. The following topics were discussed: Fracture dating-the published literature is broadly similar with respect to the identification of the radiographic stages of bony healing. The non-expert/general radiologist is encouraged to use broad descriptors of fracture healing (acute, healing or old) within their reports, rather than attempting to date fractures. The more experienced/expert radiologist, who may provide a timeframe/range to assist the courts, should be aware that any published timeframes are not absolute and that recent research indicates that the rate of healing may differ according to the bone affected and the age of the patient. Whole spine imaging in suspected abusive head trauma-this is recommended to enable a complete assessment of the neuraxis when abusive head trauma is suspected or diagnosed, particularly in the presence of intracranial and cervical subdural haemorrhage and cervical ligamentous injury. Cranial imaging in suspected physical abuse-both computed tomography (CT) and magnetic resonance imaging (MRI) remain complimentary depending on the clinical context in which they are used with CT remaining first-line in the assessment of children with (suspected abusive) head trauma prior to an early MRI. MRI is superior in its assessment of parenchymal injury and may be employed as first-line in age appropriate asymptomatic siblings of a child with suspected physical abuse.
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Affiliation(s)
- Michael Paddock
- Medical Imaging Department, Perth Children's Hospital, Perth, WA, Australia.
- Division of Paediatrics, University of Western Australia, Perth, WA, Australia.
- Department of Oncology & Metabolism, University of Sheffield, Sheffield Children's NHS Foundation Trust, Sheffield, UK.
| | - Arabinda K Choudhary
- Department of Diagnostic Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Annmarie Jeanes
- Department of Paediatric Radiology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Inès Mannes
- Paediatric Radiology Department, AP-HP, Bicêtre Hospital, Le Kremlin-Bicêtre, Paris, France
| | - Maria Raissaki
- Radiology Department, Medical School, University Hospital of Heraklion, University of Crete, Crete, Greece
| | - Catherine Adamsbaum
- Faculty of Medicine, Paris-Saclay University, Le Kremlin Bicêtre, Paris, France
| | - Maria I Argyropoulou
- Department of Radiology, Medical School, University of Ioannina, Ioannina, Greece
| | - Rick R van Rijn
- Department of Radiology and Nuclear Medicine, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Amaka C Offiah
- Department of Oncology & Metabolism, University of Sheffield, Sheffield Children's NHS Foundation Trust, Sheffield, UK
- Department of Radiology, Sheffield Children's NHS Foundation Trust, Sheffield, UK
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17
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Cunha LAMD, Pontes MDDS. Child Fractures: Are We Getting More Surgical? Rev Bras Ortop 2023; 58:191-198. [PMID: 37252311 PMCID: PMC10212633 DOI: 10.1055/s-0042-1748815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 03/28/2022] [Indexed: 10/18/2022] Open
Abstract
Historically, surgeries on the immature skeleton were reserved for open or articular fractures. In recent years, the improvement in the quality and safety of anesthesia, new imaging equipment, implants designed especially for pediatric fractures, associated with the possibility of shorter hospitalization time and rapid return to social life has demonstrated a new tendency to evaluate and treat fractures in children. The purpose of this update article is to answer the following questions: (1) Are we really turning more surgical in addressing fractures in children? (2) If this is true, is this surgical conduct based on scientific evidence? In fact, in recent decades, the medical literature demonstrates articles that support better evolution of fractures in children with surgical treatment. In the upper limbs, this is very evident in the systematization of the reduction and percutaneous fixation of supracondylar fractures of the humerus and fractures of the forearm bones. In the lower limbs, the same occurs with diaphyseal fractures of the femur and tibia. However, there are gaps in the literature. The available published studies show low scientific evidence. Thus, it can be inferred that, even though the surgical approach is more present, the treatment of pediatric fractures should always be individualized and conducted according to the knowledge and experience of the professional physician, taking into account the presence of technological resources available for the care of the small patient. All possibilities, non-surgical and/or surgical, should be included, always instituting actions based on science and in agreement with the family's wishes.
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18
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Evaluation and Management of Pediatric Humeral Shaft Fractures. J Am Acad Orthop Surg 2023; 31:265-273. [PMID: 36729652 DOI: 10.5435/jaaos-d-22-00443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/19/2022] [Indexed: 02/03/2023] Open
Abstract
Diaphyseal humerus fractures in the pediatric population have dynamic treatment strategies that depend on injury pattern, mechanism, patient skeletal maturity, and size. Treatment strategies include closed reduction with various immobilization techniques, flexible nails, uniplanar or multiplanar external fixation, or plate osteosynthesis. Accepted parameters for sagittal and coronal alignment vary based on age and potential for remodeling, and the multiplanar motion of the shoulder joint can accommodate for greater variations in alignment than many other long bone fractures. Complications such as radial nerve palsy are possible with both open and closed injuries, and mal/nonunions, although rare, can occur. Overall, treatment should be predicated on a full evaluation of the patient, fracture, local soft tissues, and any concomitant injuries.
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19
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Sweet AAR, de Bruin IGJ, Peek J, IJpma FFA, van Baal MCPM, Leenen LPH, Houwert RM. Epidemiology and outcomes of traumatic chest injuries in children: a nationwide study in the Netherlands. Eur J Pediatr 2023; 182:1887-1896. [PMID: 36807757 PMCID: PMC10167109 DOI: 10.1007/s00431-023-04828-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 02/21/2023]
Abstract
UNLABELLED Thoracic injuries are infrequent among children, but still represent one of the leading causes of pediatric mortality. Studies on pediatric chest trauma are dated, and little is known of outcomes in different age categories. This study aims to provide an overview of the incidence, injury patterns, and in-hospital outcomes of children with chest injuries. A nationwide retrospective cohort study was performed on children with chest injuries, using data from the Dutch Trauma Registry. All patients admitted to a Dutch hospital between January 2015 and December 2019, with an abbreviated injury scale score of the thorax between 2 and 6, or at least one rib fracture, were included. Incidence rates of chest injuries were calculated with demographic data from the Dutch Population Register. Injury patterns and in-hospital outcomes were assessed in children in four different age groups. A total of 66,751 children were admitted to a hospital in the Netherlands after a trauma between January 2015 and December 2019, of whom 733 (1.1%) sustained chest injuries accounting for an incidence rate of 4.9 per 100,000 person-years. The median age was 10.9 (interquartile range (IQR) 5.7-14.2) years and 62.6% were male. In a quarter of all children, the mechanisms were not further specified or unknown. Most prevalent injuries were lung contusions (40.5%) and rib fractures (27.6%). The median hospital length of stay was 3 (IQR 2-8) days, with 43.4% being admitted to the intensive care unit. The 30-day mortality rate was 6.8%. CONCLUSION Pediatric chest trauma still results in substantial adverse outcomes, such as disability and mortality. Lung contusions may be inflicted without fracturing the ribs. This contrasting injury pattern compared to adults underlines the importance of evaluating children with chest injuries with additional caution. WHAT IS KNOWN • Chest injuries are rare among children, but represent one of the leading causes of pediatric mortality. • Children show distinct injury patterns in which pulmonary contusions are more prevalent than rib fractures. WHAT IS NEW • The proportion of chest injuries among pediatric trauma patients is currently lower than reported in previous literature, but still leads to substantial adverse outcomes, such as disabilities and death. • The incidence of rib fractures gradually increases with age and in particular around puberty when ossification of the ribs becomes completed. The incidence of rib fractures among infants is remarkably high, which is strongly suggestive for nonaccidental trauma.
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Affiliation(s)
- Arthur A R Sweet
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Ivar G J de Bruin
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jesse Peek
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank F A IJpma
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Mark C P M van Baal
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Roderick M Houwert
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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20
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Kow RY, Low CL, Awang MS. Supracondylar Humerus Fractures in Infants and Toddlers: An Unexplored Area. J INVEST SURG 2023; 36:1-2. [DOI: 10.1080/08941939.2022.2136803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- R. Y. Kow
- Department of Orthopaedics, Traumatology & Rehabilitation, Sultan Ahmad Shah Medical Centre @IIUM, International Islamic University Malaysia, Kuantan, Malaysia
| | - C. L. Low
- Department of Radiology, Sultan Ahmad Shah Medical Centre @IIUM (SASMEC @IIUM), Kuantan, Malaysia
| | - M. S. Awang
- Department of Orthopaedics, Traumatology & Rehabilitation, Sultan Ahmad Shah Medical Centre @IIUM, International Islamic University Malaysia, Kuantan, Malaysia
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21
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Isaac CV, Cornelison JB, Devota CJ, Shattuck BL, Castellani RJ. An unusual blunt force trauma pattern and mechanism to the cranial vault: Investigation of an atypical infant homicide. J Forensic Sci 2023; 68:315-326. [PMID: 36331044 PMCID: PMC10098721 DOI: 10.1111/1556-4029.15168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/04/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
This case report presents an unusual fracture pattern in the cranium of a four-month-old infant indicative of child abuse. Upon postmortem examination, the infant presented with numerous bilateral linear cranial fractures running perpendicular to the sagittal suture with depressed and curvilinear fractures apparent on the supra-auricular surfaces of the cranium. Histological evidence indicates multiple traumatic events to the cranium. In addition, the stair-step pattern of a parietal fracture may represent multiple contiguous fractures from repeated loading of the head at different times with variation of the focal points of compressive force. Additionally, the left humerus, left radius, and left ulna have healing metaphyseal fractures, and the left ulna also has an antemortem diaphyseal fracture which resulted in the distal metaphysis being rotated 45 degrees medially. Integration of autopsy, anthropological, and neuropathological reports for this case suggest multiple inflicted injury episodes with a repeated atypical mechanism(s) to the cranial vault of the infant. During investigative interviews, the caretaker admitted to squeezing the infant's head and neck on multiple occasions to quiet the child. This reported abusive mechanism is consistent with the pattern of symmetric cranial fractures and soft tissue injuries indicating asphyxiation. This case report provides forensic investigators with a potential trauma mechanism to explore in cases when a similar pattern of cranial trauma is observed and highlights the need for greater research on fracture propagation and fracture healing in the infant cranium.
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Affiliation(s)
- Carolyn V Isaac
- Department of Anthropology, Michigan State University, East Lansing, Michigan, USA
| | - Jered B Cornelison
- Department of Pathology, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - Clara J Devota
- Department of Anthropology, Michigan State University, East Lansing, Michigan, USA
| | | | - Rudolph J Castellani
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
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22
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Mannes I, Drissi C, Adamsbaum C. Imaging findings in abusive head trauma (AHT). Childs Nerv Syst 2022; 38:2325-2334. [PMID: 36173471 DOI: 10.1007/s00381-022-05672-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/08/2022] [Indexed: 11/27/2022]
Abstract
Brain imaging plays a key role in accurately identifying abusive head trauma (AHT). An exact and rapid diagnosis is needed due to the extreme severity of AHT, since there is a risk of neurological sequelae and potentially fatal recurrence. Several medical specialists will work collaboratively to detect and confirm abuse in children: the radiologist has a leading role in this approach. This article describes the most common neuro-imaging patterns of AHT, including extra axial, intra axial, bony, and ligamentous lesions, with a special focus on the dating issue and the differential diagnosis.
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Affiliation(s)
- Inès Mannes
- Pediatric Radiology Department, AP-HP, Bicêtre Hospital, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
| | - Cyrine Drissi
- Pediatric Radiology Department, AP-HP, Bicêtre Hospital, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Catherine Adamsbaum
- Pediatric Radiology Department, AP-HP, Bicêtre Hospital, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
- Faculty of Medicine, Paris-Saclay University, 63 rue Gabriel Péri, 94270, Le Kremlin Bicêtre, France
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23
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Berthold O, Clemens V, Levi BH, Jarczok M, Fegert JM, Jud A. Survey on Reporting of Child Abuse by Pediatricians: Intrapersonal Inconsistencies Influence Reporting Behavior More than Legislation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15568. [PMID: 36497644 PMCID: PMC9738942 DOI: 10.3390/ijerph192315568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/14/2022] [Accepted: 11/18/2022] [Indexed: 06/17/2023]
Abstract
Background: Internationally, various laws govern reporting of child abuse to child protection services by medical professionals. Whether mandatory reporting laws are in place or not, medical professionals need internal thresholds for suspicion of abuse to even consider a report ("reasonable suspicion" in US law, "gewichtige Anhaltspunkte" in German law). Objective: To compare internal thresholds for suspicion of abuse among US and German pediatricians, i.e., from two countries with and without mandatory reporting laws. Participants and Setting: In Germany, 1581 pediatricians participated in a nationwide survey among child health professionals. In the US, a survey was mailed to all Pennsylvania pediatricians, and 1249 participated. Methods: Both samples were asked how high in their rank order of differential diagnoses child abuse would have to be when confronted with a child's injuries to qualify for reasonable suspicion/gewichtige Anhaltspunkte (differential diagnosis scale, DDS). In a second step, both had to mark a 10-point likelihood scale (0-100%) corresponding to reasonable suspicion/gewichtige Anhaltspunkte (estimated probability scale, EPS). Results: While for almost two-thirds of German pediatricians (62.4%), child abuse had to be among the top three differential diagnoses for gewichtige Anhaltspunkte, over half of the US respondents (48.1%) had a lower threshold for reasonable suspicion. On the estimated probability scale, over 65% in both samples indicated that the probability of abuse had to exceed 50% for reasonable suspicion/gewichtige Anhaltspunkte. There was great variability between the two countries. Conclusions: There are similar uncertainties in assessing cases of suspected child abuse in different legal systems. There is a need for debates on thresholds among medical professionals in both countries.
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Affiliation(s)
- Oliver Berthold
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075 Ulm, Germany
| | - Vera Clemens
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075 Ulm, Germany
| | - Benjamin H. Levi
- Departments of Humanities and Pediatrics, Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA 17033, USA
| | - Marion Jarczok
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075 Ulm, Germany
| | - Jörg M. Fegert
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075 Ulm, Germany
| | - Andreas Jud
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075 Ulm, Germany
- School of Social Work, Lucerne University of Applied Sciences and Arts, Werftestrasse 1, 6002 Lucerne, Switzerland
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24
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Lasiecka ZM, Pitot M, Chern BL, Chern JJ, Kadom N. Skull Fracture Healing in Children Up To 36 Months - A Cohort Analysis. Curr Probl Diagn Radiol 2022; 52:253-256. [PMID: 36473801 DOI: 10.1067/j.cpradiol.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022]
Abstract
During medicolegal proceedings in cases of suspected child abuse it is sometimes argued that skull fractures could be sequelae from complications at birth or resulted from a prior witnessed accidental trauma that may have preceded the suspected abusive event. There is paucity of scientific evidence indicating timing for skull fracture healing in children up to 36 months old. Objective of this study was to assess the average time to imaging documentation of skull fracture healing in children up to 36 months old. We performed retrospective chart review and image analysis in children with documented skull fractures after trauma between May 2009 and December 2014, excluding any patients who underwent cranial procedures related to the head injury, patients with pre-existing CSF shunts, patients who were referred for child abuse evaluation, and patients who were admitted to the General Surgery service for multi-organ trauma.We analyzed 185 skull fractures: 82 fractures were not healed, 49 fractures were partially healed, and 54 fractures were healed on follow-up imaging. The mean time to imaging evidence of healing among patients with healed fractures was 108 days (3.6 months), the median was 112 days (3.7 months), the minimum was 22 days, and the maximum was 225 days (7.5 months). Chi-square analysis showed a significant relationship between the skull fracture healed status and presence of bleed (P = 0.001) and with fracture characteristics of displaced, depressed, or dehiscent (P= 0.009). There was no significant association with the age group (P= 0.32) nor with involvement of multiple cranial plates (P= 0.73). This information may be useful during medicolegal proceedings in patients with suspected abusive head trauma mechanism.
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Factors Associated With Referral of Children With a Femur Fracture to a Social Worker by an Orthopedist for Suspected Child Abuse. Pediatr Emerg Care 2022; 38:613-616. [PMID: 36173342 DOI: 10.1097/pec.0000000000002855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This article explores factors associated with referral of children with a femur fracture to a social worker by an orthopedist for suspected child abuse. METHODS This retrospective chart review study included 131 children younger than 5 years who sustained a femur fracture and were hospitalized in a major 495-bed hospital located in the northern-central Israel from 2009 to 2021. Data on children who were referred to a social worker by the treating orthopedist and those who were not were compared. RESULTS More than half the children studied (58.8%, n = 77) were referred to a social worker by an orthopedist for suspected child abuse. However, only a fifth of these cases were eventually reported to the authorities. Male sex (odds ratio [OR], 2.44), younger age of the child (OR, 0.95), and spiral femur fracture type (OR, 5.30) increased the likelihood of referral. In addition, treatment of the child by an orthopedic specialist (as compared with an orthopedic resident; OR, 3.12) and lengthier professional experience of the treating orthopedist (OR, 1.08) increased the likelihood of referral. CONCLUSIONS Younger male children presenting with a spiral femur fracture have a higher likelihood to be referred to a social worker because of suspected child abuse by treating orthopedic specialists with lengthier professional experience. The findings point to the need to improve the capacity of orthopedic residents to report child abuse.
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Kim MJ, Jillian H, Rachael T, Debra W, Sean H, Sandhya R, Richie P. Is repeated childhood fracture related to areal bone density or body composition in middle age? Osteoporos Int 2022; 33:2369-2379. [PMID: 35918403 PMCID: PMC9568436 DOI: 10.1007/s00198-022-06500-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 07/04/2022] [Indexed: 11/25/2022]
Abstract
Childhood fracture is common, but whether it predicts adult fracture is not clear. Repeat childhood fracture was associated with adult (≤ 45 years) fracture, and in women, lower areal bone density was associated with repeat childhood fracture. Identifying fracture-prone children can modify adult fracture risk management. INTRODUCTION A quarter of boys and 15% of girls will suffer multiple fractures, but it is not clear whether multiple fractures during growth predict fracture risk and areal bone density in adulthood. This study evaluated whether children who repeatedly fracture were at increased risk of low areal bone density, abnormal body composition, and fractures by age 45. METHODS A subsample of a large birth cohort study with childhood fracture cases had areal bone density assessed at age 45 years. Participants were questioned regularly across their lifetime about fractures during childhood (ages 0-18 years of age) and adulthood (any fracture between 18 and 45 years). The number of fractures was collapsed into three categories: no fractures; 1 fracture; and > 1 fracture, separately for child and adult groups. RESULTS At age 45 years, areal bone mineral density (g/cm2) and body composition were measured with dual X-ray absorptiometry in n = 555 participants. Compared to no fractures, twice as many girls (14% vs 7%, P = 0.156) and boys (31.4% vs 14.1%, P = 0.004) who repeatedly fractured in childhood sustained multiple fractures as adults. Both girls and boys who were fracture-free tended to remain fracture-free as adults (79.8% compared with 62.8%, P = 0.045, and 64.8% compared with 51.4%, P = 0.025, in males and females, respectively). Participants were more than twice as likely to fracture repeatedly as adults if they had sustained multiple fractures as a child (OR 2.5 95% CI: 1.4, 4.6). Women who repeatedly fractured during childhood had lower areal bone density, whereas repeated fracturing during childhood was not associated with areal bone density or body composition in men, even after adjustment for other factors known to influence fracture history. CONCLUSION Childhood fracture history is associated with persistent skeletal fragility in adulthood (≤ 45 years), even after adjustment for behavioral and demographic factors known to influence fracture history.
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Affiliation(s)
- Meredith-Jones Kim
- Department of Medicine, University of Otago, PO Box 56, Dunedin, New Zealand.
| | - Haszard Jillian
- Biostatistics Centre, University of Otago, Dunedin, New Zealand
| | - Taylor Rachael
- Department of Medicine, University of Otago, PO Box 56, Dunedin, New Zealand
| | - Waters Debra
- Department of Medicine, University of Otago, PO Box 56, Dunedin, New Zealand
| | - Hogan Sean
- Department of Psychology, The Dunedin Multidisciplinary Health and Development Research Unit, Dunedin, New Zealand
| | - Ramrakha Sandhya
- Department of Psychology, The Dunedin Multidisciplinary Health and Development Research Unit, Dunedin, New Zealand
| | - Poulton Richie
- Department of Psychology, The Dunedin Multidisciplinary Health and Development Research Unit, Dunedin, New Zealand
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Crowe M, Byerly L, Mehlman CT. Transphyseal Distal Humeral Fractures: A 13-Times-Greater Risk of Non-Accidental Trauma Compared with Supracondylar Humeral Fractures in Children Less Than 3 Years of Age. J Bone Joint Surg Am 2022; 104:1204-1211. [PMID: 35793799 DOI: 10.2106/jbjs.21.01534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The transphyseal distal humeral fracture has been well described as a concerning fracture pattern for non-accidental trauma (NAT) in young pediatric patients. Because of the infrequent presentation of this fracture, the association historically has been anecdotal. The purpose of this study was to determine and compare the incidence of NAT among displaced transphyseal distal humeral fractures and displaced supracondylar humeral fractures in children <3 years of age. METHODS All displaced transphyseal distal humeral fractures and displaced supracondylar humeral fractures in patients <3 years of age admitted because of injury during an 18-year period were reviewed retrospectively for inclusion. Patient demographics, mechanisms of injury, results of child protective services investigations, and medical records were reviewed. A chi-square test was utilized to analyze significance for categorical data; p values of <0.05 were defined as significant. RESULTS The charts of 23 transphyseal distal humeral and 205 supracondylar humeral fracture cases were reviewed. NAT was the cause for 6 (26%) of the displaced transphyseal distal humeral fractures and 4 (2%) of the displaced supracondylar fractures. The associated risk of NAT was 13 times greater (95% confidence interval [CI], 4.05 to 43.7; p < 0.001) for children admitted for operative management of displaced transphyseal distal humeral fractures compared with those admitted for operative management of displaced supracondylar humeral fractures. CONCLUSIONS The classic 1980 paper by DeLee et al. sensitized the orthopaedic community to the relationship between transphyseal distal humeral fractures and child abuse. Our study is the first, to our knowledge, to bring statistical weight to this association. We found a 13-times-greater risk of NAT for children <3 years of age who sustain a displaced transphyseal distal humeral fracture compared with a displaced supracondylar fracture. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mary Crowe
- Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
| | - Luke Byerly
- University of Louisville School of Medicine, Louisville, Kentucky
| | - Charles T Mehlman
- Division of Pediatric Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Tadepalli V, Schultz JD, Rees AB, Wollenman LC, Louer CR, Lempert NL, Moore-Lotridge SN, Schoenecker JG. Nonaccidental Trauma in Pediatric Elbow Fractures: When You Should Be Worried. J Pediatr Orthop 2022; 42:e601-e606. [PMID: 35405731 DOI: 10.1097/bpo.0000000000002145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nonaccidental trauma (NAT) is a rising source of morbidity and mortality in the pediatric population. Fractures are often the first cause for presentation to health care providers in the case of NAT but can be misidentified as accidental. Given that elbow fractures are the most common accidental injuries among pediatric patients, they are not traditionally associated with NAT. This study aims to determine the prevalence of NAT among elbow fractures and identify common features in nonaccidental elbow fractures. METHODS Current Procedural Terminology (CPT) codes were used to retrospectively identify all pediatric (0 to 17) elbow fractures at a single, tertiary children's hospital between 2007 and 2017. Among these, all fractures for which an institutional child abuse evaluation team was consulted were identified. The medical record was then used to determine which of these fractures were due to NAT. Standard injury radiographs of all victims of NAT as well as all patients under 1 year of age were blinded and radiographically evaluated for fracture type by a pediatric orthopaedic surgeon. RESULTS The prevalence of nonaccidental elbow fractures across the 10-year study period was 0.4% (N=18). However, the prevalence of nonaccidental elbow fractures in those patients below 1 year of age was markedly higher at 30.3% (10/33). Among all elbow fractures in patients below 1 year of age, supracondylar humerus fractures were the most common fracture type (19/33, 57.6%), yet transphyseal fractures (6/33, 18.1%) were most commonly the result of NAT (5/6, 83.3%). In children over 1 year of age, fracture type was not an indicator of NAT. CONCLUSIONS The vast majority of pediatric elbow fractures (99.6%) are accidental. However, certain factors, namely age below 1 year and transphyseal fractures increase the likelihood that these fractures may be a result of NAT. LEVEL OF EVIDENCE Level IV: retrospective case series.
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Affiliation(s)
| | | | | | | | - Craig R Louer
- Department of Pharmacology, Vanderbilt University
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt
| | - Nathaniel L Lempert
- Department of Pharmacology, Vanderbilt University
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt
| | - Stephanie N Moore-Lotridge
- Department of Pharmacology, Vanderbilt University
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt
- Department of Orthopaedics
| | - Jonathan G Schoenecker
- Department of Pharmacology, Vanderbilt University
- Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt
- Department of Orthopaedics
- Department of Pediatrics
- Department of Pathology, Microbiology, and Immunology
- Center for Bone Biology, Vanderbilt University Medical Center, Nashville, TN
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Collings AT, Farazi M, Van Arendonk K, Fallat ME, Minneci PC, Sato TT, Speck KE, Deans KJ, Falcone RA, Foley DS, Fraser JD, Keller MS, Kotagal M, Landman MP, Leys CM, Markel T, Rubalcava N, St Peter SD, Flynn-O'Brien KT. Impact of "Stay-at-Home" orders on non-accidental trauma: A multi-institutional study. J Pediatr Surg 2022; 57:1062-1066. [PMID: 35292165 PMCID: PMC8842346 DOI: 10.1016/j.jpedsurg.2022.01.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 01/31/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND It is unclear how Stay-at-Home Orders (SHO) of the COVID-19 pandemic impacted the welfare of children and rates of non-accidental trauma (NAT). We hypothesized that NAT would initially decrease during the SHO as children did not have access to mandatory reporters, and then increase as physicians' offices and schools reopened. METHODS A multicenter study evaluating patients <18 years with ICD-10 Diagnosis and/or External Cause of Injury codes meeting criteria for NAT. "Historical" controls from an averaged period of March-September 2016-2019 were compared to patients injured March-September 2020, after the implementation of SHO ("COVID" cohort). An interrupted time series analysis was utilized to evaluate the effects of SHO implementation. RESULTS Nine Level I pediatric trauma centers contributed 2064 patients meeting NAT criteria. During initial SHO, NAT rates dropped below what was expected based on historical trends; however, thereafter the rate increased above the expected. The COVID cohort experienced a significant increase in the proportion of NAT patients age ≥5 years, minority children, and least resourced as determined by social vulnerability index (SVI). CONCLUSIONS The COVID-19 pandemic affected the presentation of children with NAT to the hospital. In times of public health crisis, maintaining systems of protection for children remain essential. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Amelia T. Collings
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson 125, Indianapolis, IN 46203, United State,Corresponding author
| | - Manzur Farazi
- Children's Hospital of Wisconsin, Milwaukee, WI, United States
| | | | - Mary E. Fallat
- Norton Children's Hospital, Louisville, KY, United States,Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, United State
| | - Peter C. Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States,Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Thomas T. Sato
- Children's Hospital of Wisconsin, Milwaukee, WI, United States
| | - K. Elizabeth Speck
- Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, MI, United States
| | - Katherine J. Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States,Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Richard A. Falcone
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - David S. Foley
- Norton Children's Hospital, Louisville, KY, United States,Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, United State
| | - Jason D. Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States
| | - Martin S. Keller
- Division of Pediatric Surgery, Washington University School of Medicine, St Louis, MO, United States
| | - Meera Kotagal
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Matthew P. Landman
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson 125, Indianapolis, IN 46203, United State
| | - Charles M. Leys
- Department of Surgery, Division of Pediatric Surgery, University of Wisconsin, Madison, WI, United States
| | - Troy Markel
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson 125, Indianapolis, IN 46203, United State
| | - Nathan Rubalcava
- Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, MI, United States
| | - Shawn D. St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States
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Hikichi T, Takata M, Horii T, Shimanuki K, Suganuma S, Toratani T, Shimokawa K, Yasutake H. Epidemiology of trauma-related paediatric limb fracture using a unique classification: A 10-year retrospective, single-centre study. Injury 2022; 53:2074-2080. [PMID: 35236572 DOI: 10.1016/j.injury.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/21/2022] [Accepted: 02/02/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Research regarding the epidemiology of paediatric trauma is limited. Using our unique classification, we describe paediatric trauma cases in a 10-year single-centre study to improve paediatric care. MATERIALS AND METHODS Data regarding all paediatric trauma cases were extracted using a computerised medical record system that detected fracture diagnosis and epiphyseal injury. Registry search identified cases from January 2008 to December 2017. Age, sex, type of fracture, and details of injury mechanism were analysed, and we categorised the 'falls/turnover' mechanism using a new trauma energy classification based on speed and height. RESULTS A total of 1379 cases (953 boys and 426 girls) were included. The highest number of injuries (553 cases, 40%) was seen in school children (aged 6 to 10 years). Forearm fracture occurred most frequently, followed by humeral fracture. The most frequent injury mechanism in falls/turnover (969 cases, 70%) was sports in 272 cases (28%), playground equipment in 179 cases (18%), furniture in 102 cases (11%), and bicycling in 87 cases (9%). We classified 956 cases of falls/turnover using our trauma energy classification scheme. Most cases (29%) were classified into the L2 category (low height and high speed), followed by the L1 category (low height and low speed) (p < 0.01). Subcategory analysis using the classification revealed that younger children were more likely to be injured by falling from high places because of their physique, whereas older children were more likely to be injured by a turnover from lower places and at higher speed. CONCLUSION We describe the epidemiology of fractures in detail and present a new classification system, which may aid in understanding the injury mechanism independent of children's height. The fact that paediatric fractures occur at relatively low energy levels and are trended by age, activity, and sex, could be of potential universal use for their prevention and parent education.
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Affiliation(s)
- Toshifumi Hikichi
- Department Orthopedics, Kanazawa University Hospital, Takara-machi 13-1, Kanazawa, Ishikawa 920-8641, Japan
| | - Munetomo Takata
- Department Orthopedics, Ishikawa Prefectural Central Hospital, Kuratsuki-higashi 2-1, Kanazawa, Ishikawa 920-8530, Japan.
| | - Takeshi Horii
- Department Orthopedics, Toyama City Hospital, Imaizumi-hokubu-machi 2-1, Toyama, Toyama 939-8511, Japan.
| | - Keito Shimanuki
- Department Orthopedics, Ishikawa Prefectural Central Hospital, Kuratsuki-higashi 2-1, Kanazawa, Ishikawa 920-8530, Japan
| | - Seigo Suganuma
- Department Orthopedics, Ishikawa Prefectural Central Hospital, Kuratsuki-higashi 2-1, Kanazawa, Ishikawa 920-8530, Japan
| | - Tatsuhiro Toratani
- Toratani Orthopaedic & Sports Clinic., Fujiekita4-342, Kanazawa, Ishikawa 920-0345, Japan
| | - Kanu Shimokawa
- Department Orthopedics, Kanazawa University Hospital, Takara-machi 13-1, Kanazawa, Ishikawa 920-8641, Japan
| | - Hidetoshi Yasutake
- Department Orthopedics, Ishikawa Prefectural Central Hospital, Kuratsuki-higashi 2-1, Kanazawa, Ishikawa 920-8530, Japan
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Jin YT, Chen CM, Huang YC, Chung CH, Sun CA, Huang SH, Chien WC, Wu GJ. Segregating Suspected Child Maltreatment from Non-Child Maltreatment Injuries: A Population-Based Case-Control Study in Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084591. [PMID: 35457455 PMCID: PMC9026454 DOI: 10.3390/ijerph19084591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/24/2022] [Accepted: 03/31/2022] [Indexed: 11/16/2022]
Abstract
Objective: To identify the differential patient characteristics, injury types, and treatment outcomes between hospitalized child abuse and non-child abuse injuries in Taiwan. Methods: Using the data from the National Health Insurance Research Database, we selected a total of 1525 patients under the age of 18 that were diagnosed with child abuse, as well as an additional 6100 patients as a comparison group. Chi-square test, Fisher exact test, and independent samples t-test were used to compare the differences between the abused children and the non-abuse-related injured children. The multivariate conditional logistic regression was performed to measure the risk factor of child maltreatment in injured children. Results: Intracranial injury was more frequent in the child abuse group than it was in the non-child abuse group (35.0% vs. 8.2%; p < 0.001). Children in the child abuse group tended to stay longer in the hospital and incur higher medical expenses (8.91 days vs. 4.41 days and USD 2564 vs. USD 880, respectively). In multivariate analysis, the Adjusted Odds Ratio (Adjusted OR) of abuse resulting in an injury for children in low-income families is 1.965 times higher than those in non-low-income families (p < 0.001). Children living in high urbanization areas had a significantly higher probability of being abused than those living in low urbanization areas (p < 0.001). Conclusion: Children under the age of 1 who were hospitalized with severe intracranial injuries are highly at risk for child maltreatment. Moreover, numerous high-risk environmental factors were observed in child abuse cases, including living in urban areas, families with low income, and seasonality, as child maltreatment cases occur more frequently in autumn.
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Affiliation(s)
- Yo-Ting Jin
- Department of Nursing, Fu-Jen Catholic University, New Taipei City 242062, Taiwan; (Y.-T.J.); (C.-M.C.)
- School of Nursing, National Taipei University of Nursing & Health Sciences, Taipei 11219, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei 11490, Taiwan
| | - Chin-Mi Chen
- Department of Nursing, Fu-Jen Catholic University, New Taipei City 242062, Taiwan; (Y.-T.J.); (C.-M.C.)
| | - Yao-Ching Huang
- Department of Chemical Engineering and Biotechnology, National Taipei University of Technology (Taipei Tech), Taipei 10608, Taiwan;
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan; (C.-H.C.); (S.-H.H.)
| | - Chi-Hsiang Chung
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan; (C.-H.C.); (S.-H.H.)
- School of Public Health, National Defense Medical Center, Taipei 11490, Taiwan
- Taiwanese Injury Prevention and Safety Promotion Association, Taipei 11490, Taiwan
| | - Chien-An Sun
- Big Data Research Center, College of Medicine, Fu-Jen Catholic University, New Taipei City 242062, Taiwan;
- Department of Public Health, College of Medicine, Fu-Jen Catholic University, New Taipei City 242062, Taiwan
| | - Shi-Hao Huang
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan; (C.-H.C.); (S.-H.H.)
| | - Wu-Chien Chien
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan; (C.-H.C.); (S.-H.H.)
- School of Public Health, National Defense Medical Center, Taipei 11490, Taiwan
- Taiwanese Injury Prevention and Safety Promotion Association, Taipei 11490, Taiwan
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei 11490, Taiwan
- Correspondence: (W.-C.C.); (G.-J.W.)
| | - Gwo-Jang Wu
- Department of Nursing, Fu-Jen Catholic University, New Taipei City 242062, Taiwan; (Y.-T.J.); (C.-M.C.)
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan; (C.-H.C.); (S.-H.H.)
- Obstetrics and Gynecology Department, Tri-Service General Hospital, Taipei 11490, Taiwan
- Correspondence: (W.-C.C.); (G.-J.W.)
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Cinematic rendering of paediatric musculoskeletal pathologies: initial experiences with CT. Clin Radiol 2022; 77:274-282. [PMID: 35164928 DOI: 10.1016/j.crad.2022.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 01/06/2022] [Indexed: 11/22/2022]
Abstract
Cinematic rendering (CR) is a novel post-processing technique similar to volume rendering (VR), which allows for a more photorealistic imaging reconstruction by using a complex light modelling algorithm, incorporating information from multiple light paths and predicted photon scattering patterns. Several recent publications relating to adult imaging have argued that CR gives a better "realism" and "expressiveness" experience over VR techniques. CR has also been shown to improve visualisation of musculoskeletal and vascular anatomy compared with conventional CT viewing, and may help non-radiologists to understand complex patient anatomy. In this review, we provide an overview of how CR could be used in paediatric musculoskeletal imaging, particularly in complex diagnoses, surgical planning, and patient consent processes. We present a direct comparison of VR and CR reconstructions across a range of congenital and acquired musculoskeletal pathologies, highlighting potential advantages and areas for further research.
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Henry MK, Schilling S, Shults J, Feudtner C, Katcoff H, Egbe TI, Johnson MA, Andronikou S, Wood JN. Practice Variation in Use of Neuroimaging Among Infants With Concern for Abuse Treated in Children's Hospitals. JAMA Netw Open 2022; 5:e225005. [PMID: 35442455 PMCID: PMC9021910 DOI: 10.1001/jamanetworkopen.2022.5005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Infants who appear neurologically well and have fractures concerning for abuse are at increased risk for clinically occult head injuries. Evidence of excess variation in neuroimaging practices when abuse is suspected may indicate opportunity for quality and safety improvement. OBJECTIVE To quantify neuroimaging practice variation across children's hospitals among infants with fractures evaluated for abuse, with the hypothesis that hospitals would vary substantially in neuroimaging practices. As a secondary objective, factors associated with neuroimaging use were identified, with the hypothesis that age and factors associated with potential biases (ie, payer type and race or ethnicity) would be associated with neuroimaging use. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included infants with a femur or humerus fracture or both undergoing abuse evaluation at 44 select US children's hospitals in the Pediatric Health Information System (PHIS) from January 1, 2016, through March 30, 2020, including emergency department, observational, and inpatient encounters. Included infants were aged younger than 12 months with a femur or humerus fracture or both without overt signs or symptoms of head injury for whom a skeletal survey was performed. To focus on infants at increased risk for clinically occult head injuries, infants with billing codes suggestive of overt neurologic signs or symptoms were excluded. Multivariable logistic regression was used to investigate demographic, clinical, and temporal factors associated with use of neuroimaging. Marginal standardization was used to report adjusted percentages of infants undergoing neuroimaging by hospital and payer type. Data were analyzed from March 2021 through January 2022. EXPOSURES Covariates included age, sex, race and ethnicity, payer type, fracture type, presentation year, and hospital. MAIN OUTCOMES AND MEASURES Use of neuroimaging by CT or MRI. RESULTS Of 2585 infants with humerus or femur fracture or both undergoing evaluations for possible child abuse, there were 1408 (54.5%) male infants, 1726 infants (66.8%) who were publicly insured, and 1549 infants (59.9%) who underwent neuroimaging. The median (IQR) age was 6.1 (3.2-8.3) months. There were 748 (28.9%) Black non-Hispanic infants, 426 (16.5%) Hispanic infants, 1148 (44.4%) White non-Hispanic infants. In multivariable analyses, younger age (eg, odds ratio [OR] for ages <3 months vs ages 9 to <12 months, 13.2; 95% CI, 9.54-18.2; P < .001), male sex (OR, 1.47; 95% CI, 1.22-1.78; P < .001), payer type (OR for public vs private insurance, 1.48; 95% CI, 1.18-1.85; P = .003), fracture type (OR for femur and humerus fracture vs isolated femur fracture, 5.36; 95% CI, 2.11-13.6; P = .002), and hospital (adjusted range in use of neuroimaging, 37.4% [95% CI 21.4%-53.5%] to 83.6% [95% CI 69.6%-97.5%]; P < .001) were associated with increased use of neuroimaging, but race and ethnicity were not. Publicly insured infants were more likely to undergo neuroimaging (62.0%; 95% CI, 60.0%-64.1%) than privately insured infants (55.1%; 95% CI, 51.8%-58.4%) (P = .001). CONCLUSIONS AND RELEVANCE This study found that hospitals varied in neuroimaging practices among infants with concern for abuse. Apparent disparities in practice associated with insurance type suggest opportunities for quality, safety, and equity improvement.
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Affiliation(s)
- M. Katherine Henry
- Safe Place: Center for Child Protection and Health, Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Samantha Schilling
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | - Justine Shults
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Chris Feudtner
- Division of General Pediatrics, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Medical Ethics, Children's Hospital of Philadelphia
| | - Hannah Katcoff
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Teniola I. Egbe
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mitchell A. Johnson
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Savvas Andronikou
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Joanne N. Wood
- Safe Place: Center for Child Protection and Health, Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Policy Lab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Liu WY, Tung TH, Zhou Y, Gu DT, Chen HY. The Relationship Between Knowledge, Attitude, Practice, and Fall Prevention for Childhood in Shanghai, China. Front Public Health 2022; 10:848122. [PMID: 35359797 PMCID: PMC8963735 DOI: 10.3389/fpubh.2022.848122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundEarly childhood fall is a pressing global public health problem and one of the leading causes of child injury. China has a high proportion of children and a high burden of illness from falls. Therefore, educational interventions to prevent childhood fall would be beneficial.MethodsWe used the outcome of knowledge, attitude and practice questionnaire, which was conducted by Pudong New District of Shanghai Municipal Government, to summarize demographic and baseline characteristics grouped by intervention or not, and analyzed descriptive statistics of continuous and categorical variables. A logistic stepwise function model was established to study the influence of different covariables on the degree of injury, and AIC/BIC/AICC was used to select the optimal model. Finally, we carried out single-factor analysis and established a multifactor model by the stepwise function method.ResultsAttitude and actual behavior scores had significant differences. The intervention and control groups had 20.79 ± 3.20 and 20.39 ± 2.89 attitude scores, respectively. Compared to the control group (5.97 ± 1.32), the intervention group had higher actual behavior scores (5.75 ± 1.50). In the univariate analysis results, fathers' education level, mothers' education level, actual behavior and what cares for children had a significant influence on whether children got injured. In multivariate analysis, attitude had a positive influence on whether injured [odds ratio: 1.13 (1.05–1.21), P < 0.001].ConclusionEducational intervention for children and their guardians can effectively reduce the risk of childhood falls, and changes in behavior and attitude are the result of educational influence. Education of childhood fall prevention can be used as a public health intervention to improve children's health.
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Affiliation(s)
- Wen-Yi Liu
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
- Shanghai Bluecross Medical Science Institute, Shanghai, China
- Institute for Hospital Management, Tsing Hua University, Shenzhen, China
| | - Tao-Hsin Tung
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated with Wenzhou Medical University, Linhai, China
| | - Yi Zhou
- Science Research and Information Management Section, Shanghai Pudong New Area Center for Disease Control and Prevention, Shanghai, China
- Pudong Institute of Preventive Medicine, Fudan University, Shanghai, China
| | - Dan Tong Gu
- Clinical Research Center, Institute of Otolaryngology, Fudan University Affiliated Eye and ENT Hospital, Shanghai, China
- Dan Tong Gu
| | - Han Yi Chen
- Science Research and Information Management Section, Shanghai Pudong New Area Center for Disease Control and Prevention, Shanghai, China
- Pudong Institute of Preventive Medicine, Fudan University, Shanghai, China
- *Correspondence: Han Yi Chen
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Love JC, Austin D, Giese KW, Roe SJ. Cardiopulmonary Resuscitation Induced Posterior Rib Fractures in Nontraumatic Pediatric Deaths. Am J Forensic Med Pathol 2022; 43:55-59. [PMID: 35020605 DOI: 10.1097/paf.0000000000000743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Posterior rib fractures are considered suspicious for nonaccidental injury when observed in infants without significant trauma history or underlying bone disease. The biomechanical mechanism postulated for causing posterior rib fractures is anterior/posterior compression of the chest with posterior levering of the rib head over the transverse process of the vertebra creating a focal area of stress. The recommended "2-thumb" cardiopulmonary resuscitation method involves the administrator placing both thumbs on the sternum of the patient, encircling the chest with the hands, and placing the finger tips lateral to the spine. From this position, the administrator compresses the chest in an anterior/posterior direction by pressing on the sternum. Theoretically, the 2-thumb method should focus all force on the sternum while the back is supported by the fingers limiting posterior levering of the ribs and reducing the risk of posterior rib fractures. However, posterior rib fractures have been found during the autopsy of infants who received 2-thumb cardiopulmonary resuscitation, had no traumatic history, had a nontraumatic cause of death, and had no indication of underlying bone disease. This case study series presents the demographics, birth histories, circumstances surrounding death, and autopsy findings of four such medical examiner cases.
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Affiliation(s)
- Jennifer C Love
- From the District of Columbia Office of the Chief Medical Examiner, Washington, DC
| | - Dana Austin
- Tarrant County Office of the Chief Medical Examiner, Fort Worth, TX
| | - Kristinza W Giese
- From the District of Columbia Office of the Chief Medical Examiner, Washington, DC
| | - Susan J Roe
- Tarrant County Office of the Chief Medical Examiner, Fort Worth, TX
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Wessels RM, Moodley H. Fatal non-accidental injury in South Africa: A Gauteng hospital’s perspective on the incidence and fracture types in post-mortem skeletal surveys. SA J Radiol 2022; 26:2311. [PMID: 35284098 PMCID: PMC8905488 DOI: 10.4102/sajr.v26i1.2311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/02/2021] [Indexed: 11/29/2022] Open
Abstract
Background In its severest form, non-accidental injury (NAI) in children is fatal. South Africa has been reported to have double the global average of child homicides. Autopsy is the main investigation in fatal NAI with post-mortem skeletal surveys (PMSS) playing an adjunctive role. Whilst fracture patterns associated with NAI in living patients have been established, this has not been investigated in PMSS in South Africa. Objectives To determine the incidence and characteristics of fractures in suspected fatal NAI cases. To calculate the incidence of fractures according to high-, moderate- and low-specificity fracture locations for NAI. Methods A retrospective review of all PMSS performed between 01 January 2012 and 03 December 2018 was conducted at the Charlotte Maxeke Johannesburg Academic Hospital. Results Of the 73 PMSS, 33 (45.2%) demonstrated fractures. No statistical significance in sex was found: 38 (52.1%) were male and 35 (47.9%) were female (p > 0.05). The mean age of those who sustained fractures was 28 months (standard deviation [s.d.]: 21 months). A total of 115 fractures were sustained, of that the top five bones fractured were the ribs 37 (32.2%), parietal bone 13 (11.3%), ulna 13 (11.3%), femur 13 (11.3%), and radius 11 (9.6%). High-specificity fracture locations accounted for 40/133 (30.1%). Conclusion The fracture types in PMSS were similar to those in live skeletal surveys. Our study’s fracture rate was higher in comparison to international studies. The PMSS is a valuable adjunct to autopsy in detecting occult fractures of the limbs. We recommend that PMSS be performed in suspected fatal NAI cases at least in children up to 24 months of age.
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Affiliation(s)
- Robyn M Wessels
- Department of Diagnostic Radiology, Faculty of Radiation Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Halvani Moodley
- Department of Diagnostic Radiology, Faculty of Radiation Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
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Otjen JP, Menashe SJ, Romberg EK, Brown ECB, Iyer RS. Pearls and Pitfalls of Thoracic Manifestations of Abuse in Children. Semin Ultrasound CT MR 2022; 43:51-60. [PMID: 35164910 DOI: 10.1053/j.sult.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Child abuse is a broad term that includes, but is not limited to, physical or emotional harm, neglect, sexual abuse, and exploitation. In 2018 in the United States, there were nearly 700,000 victims of such maltreatment, of which 1700 children died. The majority of deaths occur in infants and toddlers under 3 years of age. While clinical signs and symptoms may raise suspicion for inflicted injury, such as bruising in young infants, imaging often plays a central role in identifying and characterizing nonaccidental trauma. The purpose of this article is to discuss the array of inflicted traumatic injuries to the thorax in children. Rib fractures are among the most common and telling features of physical abuse, especially in infants. The locations of such fractures and differences in appearance while healing will be presented, along with potential mimics and pitfalls. Less typical fractures seen in abuse will also be reviewed, including those of the sternum, clavicle, spine, and scapula. Finally, uncommon injuries to the lungs, heart and esophagus will also be considered.
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Affiliation(s)
- Jeffrey P Otjen
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Sarah J Menashe
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Erin K Romberg
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Emily C B Brown
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Ramesh S Iyer
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA.
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Bataenjer R, Grotzer M, Seiler M. For Infants With Fractures: Involvement of a Child Protection Team Is Mandatory With Few Exceptions. Pediatr Emerg Care 2022; 38:e724-e730. [PMID: 35100770 DOI: 10.1097/pec.0000000000002325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to compare the frequency at which abuse is detected in institutions with mandatory skeletal surveys for infants with fractures to that in institutions with discretionary referral to child protection teams (CPTs). METHODS A retrospective chart review of all infants with fractures diagnosed at an emergency department from 2014 to 2018 was conducted to analyze factors leading to a discretionary referral to CPTs and to identify the frequency of nonaccidental trauma. RESULTS Seventy-two infants with a median age of 6 months were included in this study. The most frequent fracture site was the skull (73.6%), followed by fractures of the femur (12.5%) and the upper arm and forearm (each 4.2%). Discretionary referral to a CPT occurred in only 25% of cases, and abuse was detected in 2.8%. CONCLUSIONS The abuse detection rate in institutions with discretionary CPT referral is lower than that in institutions with mandatory skeletal surveys. Therefore, we recommend that in institutions with no mandatory skeletal surveys for infants with fractures, every infant with a fracture must be discussed with a CPT.
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Affiliation(s)
- Reto Bataenjer
- From the Pediatric Emergency Department, University Children's Hospital
| | - Michael Grotzer
- Children's Research Center, University Children's Hospital and University of Zurich, Zurich, Switzerland
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Uçan B, Tokur O, Aydın S. Pediatric skull fractures: could suture contact be a sign of abuse? Emerg Radiol 2022; 29:403-408. [PMID: 35044547 DOI: 10.1007/s10140-022-02024-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/13/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Skull fractures in infants and young children can occur as a result of both accidental trauma and abuse. 1/3 of children with abuse-related head trauma and 1/5 of children with abuse-related fractures were overlooked during the initial evaluation. In this study, we aim to investigate the prevalence of skull fractures that come into contact with the suture in head traumas caused by accidents and abuse, and also to see if contact of the fracture line with the suture could be used as a sign for abuse in the pediatric population. METHODS Forry-four patients with head trauma were retrospectively assessed between January 2010 and June 2020 and were confirmed to have fractures on a brain CT. Patient age, gender, and head injury type were recorded. The fracture site, location and number, the contact of the fracture line with the suture, the name, and number of the suture it came into contact with were determined. RESULTS Twenty-eight skull fractures in 22 children with a diagnosis of child abuse and 25 skull fractures in 22 children due to accidental trauma were evaluated in the same age and gender range. Eighteen (64%) of 28 abuse-related skull fractures were in contact with two or more sutures. Two (8%) of 25 accident-related fractures were related to two or more sutures. Abuse-related fractures had a significantly higher suture contact rate than accident-related fractures (p = 0.007). CONCLUSION Contact with two or more sutures of a skull fracture is a finding related to abuse rather than accident.
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Affiliation(s)
- Berna Uçan
- Department of Radiology, Dr. Sami Ulus Training and Research Hospital, Ankara, Turkey
| | - Oğuzhan Tokur
- Department of Radiology, Ankara Training and Research Hospital, Ankara, Turkey.
| | - Sonay Aydın
- Department of Radiology, Faculty of Medicine, Erzincan Binali Yildirim University, Erzincan, Turkey
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Metz JB, Otjen JP, Perez FA, Done SL, Brown ECB, Wiester RT, Jenny C, Kelton MC, Ganti SN, Feldman KW. Are Complex Skull Fractures Indicative of Either Child Abuse or Major Trauma in the Era of 3-Dimensional Computed Tomography Imaging? Pediatr Emerg Care 2022; 38:e200-e204. [PMID: 32868622 DOI: 10.1097/pec.0000000000002214] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The aim of the study was to determine whether complex skull fractures are more indicative of child abuse or major trauma than simple skull fractures. DESIGN This is a retrospective chart and imaging review of children diagnosed with a skull fracture. Subjects were from 2 pediatric tertiary care centers. Children younger than 4 years who underwent a head computed tomography with 3-dimensional rendering were included. We reviewed the medical records and imaging for type of skull fracture, abuse findings, and reported mechanism of injury. A complex skull fracture was defined as multiple fractures of a single skull bone, fractures of more than 1 skull bone, a nonlinear fracture, or diastasis of greater than 3 mm. Abuse versus accident was determined at the time of the initial evaluation with child abuse physician team confirmation. RESULTS From 2011 to 2012, 287 subjects were identified by International Classification of Diseases, Ninth Revision, code. The 147 subjects with a cranial vault fracture and available 3-dimensional computed tomography composed this study's subjects. The average age was 12.3 months. Seventy four (50.3%) had complex and 73 (49.7%) had simple fractures. Abuse was determined in 6 subjects (4.1%), and a determination could not be made for 5 subjects. Adding abused children from 2013 to 2014 yielded 15 abused subjects. Twelve of the abused children (80%) had complex fractures; more than the 66 (48.5%) of 136 accidentally injured children (P = 0.001; relative risk = 1.65 [1.21-2.24]). However, among children with a complex fracture, the positive predictive value for abuse was only 7%. CONCLUSIONS Complex skull fractures frequently occur from accidental injuries. This study suggests that the presence of complex skull fractures should not be used alone when making a determination of abuse.
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Affiliation(s)
- James B Metz
- Department of Pediatrics, University of Vermont Children's Hospital, Burlington, VT
| | | | | | | | - Emily C B Brown
- Children's Protection Program, General Pediatric Division University of Washington, Seattle Children's Hospital
| | - Rebecca T Wiester
- Children's Protection Program, General Pediatric Division University of Washington, Seattle Children's Hospital
| | - Carole Jenny
- Children's Protection Program, General Pediatric Division University of Washington, Seattle Children's Hospital
| | | | | | - Kenneth W Feldman
- Children's Protection Program, General Pediatric Division University of Washington, Seattle Children's Hospital
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Cohrs G, Winter SM, Siska W, Thomale UW. Underestimating isolated bilateral hygroma as non-accidental head injury with dramatic consequences: a case presentation. Childs Nerv Syst 2022; 38:2429-2435. [PMID: 36323956 PMCID: PMC9630064 DOI: 10.1007/s00381-022-05720-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Abusive head injury (AHI) in infancy is associated with significantly worse outcomes compared to accidental traumatic brain injury. The decision-making of the diagnosis of AHI is challenging especially if the clinical signs are not presenting as a multifactorial pattern. METHOD We present a case of isolated bilateral hygroma in which this differential diagnosis of AHI was evaluated but primarily not seen as such leading subsequently to extensive secondary AHI with fatal brain injury. RESULTS The case of an 8-week-old infant with apparently isolated bilateral hygroma without any external signs of abuse and no retinal hemorrhages was interpreted in causative correlation to the perinatal complex course of delivery. At a second readmission of the case, severe brain injury with bilateral cortical hypoxia, subarachnoid and subdural hemorrhages, and skull and extremity fractures led to severe disability of the affected infant. CONCLUSION Any early suspicion of AHI with at least one factor possibly being associated with abusive trauma should be discussed in multidisciplinary team conferences to find the best strategy to protect the child. Beside clinical factors, social factors within the family household may additionally be evaluated to determine stress-related risk for traumatic child abuse. In general, prevention programs will be essential in future perspective.
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Affiliation(s)
- Gesa Cohrs
- Pediatric Neurosurgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sibylle Maria Winter
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany ,Child Protection Team, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Wiebke Siska
- Child Protection Team, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrich-Wilhelm Thomale
- Pediatric Neurosurgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany.
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Watanabe Y, Shiga K, Kikuchi N, Kurihara Y, Sato A. A regional multidisciplinary network enhances child abuse case management. Pediatr Int 2022; 64:e15240. [PMID: 35859263 DOI: 10.1111/ped.15240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/01/2022] [Accepted: 05/12/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND We previously reported an inadequate response to intracranial hemorrhage (ICH) cases under 24 months of age in Yokohama from 2011 to 2013. Hence, it is very important to evaluate how the establishment of a regional multidisciplinary network for child abuse affects the response to ICH cases in medical institutions. METHODS We conducted a questionnaire survey of ICH cases under 24 months of age from 2014 to 2016 using a regional multidisciplinary network for child abuse established in Yokohama in September 2013. We investigated the patients' characteristics, examinations to identify inflicted injury, and reports made to the hospital-based child protection team (CPT) or regional child protective service (CPS), and compared the results of a previous study and the current study, which corresponds to before and after the establishment of the regional network, respectively. RESULTS The total number of ICH cases was 50 in 3 years. The number of cases surveyed for covert fracture and fundus hemorrhage increased significantly after the establishment of the regional network (P = 0.0001 and P = 0.0182, respectively). The number of cases reported as suspected child abuse was 41 (82%) to the hospital-based CPTs and 27 (54%) to the regional CPSs. There were significant differences between before and after the establishment of the regional network regarding CPT (P = 0.0062) and CPS (P = 0.0215) reports. CONCLUSIONS A regional multidisciplinary network can enhance response and cooperation to address child abuse. It deepens our understanding of such care and improves awareness by hospital personnel of child abuse.
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Affiliation(s)
- Yoshihiro Watanabe
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Japan.,Children's Medical Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Kentaro Shiga
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Japan.,Children's Medical Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Nobuyuki Kikuchi
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Japan.,Department of Pediatrics, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Yachiyo Kurihara
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Japan.,Department of Pediatrics, St. Marianna University Yokohama City Seibu Hospital, Yokohama, Japan
| | - Atsuo Sato
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Japan.,Department of Pediatrics, Yokohama Rosai Hospital, Yokohama, Japan
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Prevalence of inflicted and neglectful femur shaft fractures in young children in national level I trauma centers. Pediatr Radiol 2022; 52:2359-2367. [PMID: 35523968 PMCID: PMC9616777 DOI: 10.1007/s00247-022-05378-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 03/11/2022] [Accepted: 04/06/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND The prevalence of inflicted femur fractures in young children varies (1.5-35.2%), but these data are based on small retrospective studies with high heterogeneity. Age and mobility of the child seem to be indicators of inflicted trauma. OBJECTIVE This study describes other factors associated with inflicted and neglectful trauma that can be used to distinguish inflicted and neglectful from accidental femur fractures. MATERIALS AND METHODS This retrospective study included children (0-6 years) who presented with an isolated femur fracture at 1 of the 11 level I trauma centers in the Netherlands between January 2010 and January 2016. Outcomes were classified based on the conclusions of the Child Abuse and Neglect teams or the court. Cases in which conclusions were unavailable and there was no clear accidental cause were reviewed by an expert panel. RESULTS The study included 328 children; 295 (89.9%) cases were classified as accidental trauma. Inflicted trauma was found in 14 (4.3%), while 19 (5.8%) were cases of neglect. Indicators of inflicted trauma were age 0-5 months (29%, positive likelihood ratio [LR +] 8.35), 6-12 months (18%, LR + 5.98) and 18-23 months (14%, LR + 3.74). Indicators of neglect were age 6-11 months (18%, LR + 4.41) and age 18-23 months (8%, LR + 1.65). There was no difference in fracture morphology among groups. CONCLUSION It is unlikely that an isolated femur fracture in ambulatory children age > 24 months is caused by inflicted trauma/neglect. Caution is advised in children younger than 24 months because that age is the main factor associated with inflicted trauma/neglect and inflicted femur fractures.
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Brennan B, Henry MK, Altaffer A, Wood JN. Prevalence of Abuse and Additional Injury in Young Children With Rib Fractures as Their Presenting Injury. Pediatr Emerg Care 2021; 37:e1451-e1456. [PMID: 32205804 DOI: 10.1097/pec.0000000000002071] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The primary objective of this study was to determine the prevalence of (a) additional injuries, (b) abuse as determined by a standardized scale, and (c) reports to child protective services (CPS) among children younger than 5 years in whom a rib fracture was the first presenting injury concerning for abuse. METHODS A retrospective study of children younger than 5 years diagnosed with rib fractures at a tertiary pediatric hospital between 2007 and 2018 was performed. Children in motor vehicle crashes, hospitalized after birth, or with previously diagnosed metabolic bone disease were excluded. We included only those children whose rib fractures were the first presenting injury. Demographic and clinical information was abstracted from the records. Prevalence of additional injuries, a diagnosis of abuse, and a report to CPS were calculated. Associations between patient demographic and clinical characteristics and the outcomes of interest were examined. RESULTS Of the 67 cases included, additional injuries concerning for abuse were identified in 40 (60%), and 58% were deemed likely or definite abuse. Reports to CPS were filed in 72% of cases. Posterior rib fractures, multiple rib fractures, and presence of rib fractures of multiple ages were all associated with presence of additional injuries and classification as definite or likely abuse (all P ≤ 0.05). CONCLUSIONS The presence of a rib fracture in young children is associated with a high likelihood of additional concerning injuries and should prompt a thorough evaluation for child abuse.
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Affiliation(s)
| | | | - Ana Altaffer
- University of Pennsylvania Perelman School of Medicine
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Ruest S, Kanaan G, Moore JL, Goldberg AP. Pediatric Rib Fractures Identified by Chest Radiograph: A Comparison Between Accidental and Nonaccidental Trauma. Pediatr Emerg Care 2021; 37:e1409-e1415. [PMID: 32371752 DOI: 10.1097/pec.0000000000002061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to determine the prevalence of rib fractures (RFs) identified by chest x-ray (CXR) among children younger than 2 years who sustained accidental versus nonaccidental injuries. It is hypothesized that RFs are uncommon among all accidental pediatric trauma mechanisms (eg, falls, motor vehicle crashes) as compared with the prevalence of RFs in the setting of nonaccidental trauma (NAT). METHODS A retrospective chart review of sequential CXRs of children younger than 2 years evaluated at a pediatric level 1 trauma center for accidental trauma and possible NAT was conducted from January 1, 2011, to October 31, 2016. Data collected included demographics, CXR indication and findings, history of cardiopulmonary resuscitation, trauma mechanism, associated injuries, final diagnoses, and outcomes. RESULTS Two (<1%) of 226 CXRs obtained to evaluate accidental trauma demonstrated acute RFs. Ten (19.6%) of 51 CXRs obtained in the setting of concern for NAT revealed RFs (9/10 identified only healing RFs and 1/10 identified acute RFs). Among patients with a final diagnosis of NAT (ie, not neglect, accidental trauma, etc; n = 38), the overall prevalence increased to 26.3%. CONCLUSIONS The presence of RFs in pediatric accidental trauma is uncommon even in the setting of high-force mechanisms, and when identified, these RFs are acute. Comparatively, the overall prevalence of RFs identified on CXR among cases with a final diagnosis of NAT was much higher and almost exclusively healing RFs. These data provide support that identification of RFs is highly concerning for NAT even if an accidental mechanism is provided. When RFs are identified, a full NAT work-up should be considered.
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Affiliation(s)
| | - Ghid Kanaan
- From the Division of Pediatric Emergency Medicine, Hasbro Children's Hospital
| | - Jessica L Moore
- Department of Pediatrics Child Protection Program, Hasbro Children's Hospital, Providence, RI
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Adult retrospective report of child abuse and prospective indicators of childhood harm: a population birth cohort study. BMC Med 2021; 19:286. [PMID: 34839815 PMCID: PMC8628375 DOI: 10.1186/s12916-021-02164-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 10/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aim to determine whether adult retrospective report of child abuse is associated with greater risk of prospectively assessed harmful environments in childhood. We assessed possible recall basis by adult depression status. METHODS At 45 years, participants of the 1958 British birth cohort (N = 9308) reported a range of abuse types (by 16 years). Prospective data, ages 7-16 years, were obtained for impoverished upbringing, hazardous conditions, anti-social behaviours and 16 years poor parent-child relationships. We estimated associations between retrospective report of child abuse and prospectively measured harm using (i) odds ratios (ORs, 95% confidence intervals) and (ii) positive predictive values (PPVs). PPVs were calculated stratified by adult depression status. RESULTS Prevalence of retrospectively reported abuse ranged from 10.7% (psychological) to 1.60% (sexual) and 14.8% reported ≥ 1 type; prospectively recorded harm ranged from 10% (hazardous conditions/poor parent-child relationships) to 20% (anti-social behaviours). Adults retrospectively reporting abuse were more likely to have had harmful childhood environments: 52.4% had ≥ 1 indicator of harm (vs. 35.6% among others); ORsex-adjusted for poor relationships with parents was 2.98 (2.50, 3.54). For retrospectively reported (vs. none) abuse, there was a trend of increasing relative risk ratio with number of harms, from 1.75 (1.50, 2.03) for 1 to 4.68 (3.39, 6.45) for 3/4 childhood harms. The PPV of ≥ 1 prospectively recorded harm did not differ between depressed (0.58 (0.52, 0.64)) and non-depressed (0.58 (0.55, 0.61)) groups. CONCLUSIONS In a population cohort, adult retrospective report of child abuse was associated with several harms, prospectively measured from childhood to adolescence, providing support for the validity of retrospective report-based research. Findings suggest retrospectively reported child abuse is not biased by depression in adulthood.
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Goldner D, Vittorio J, Barrios DM, McGuire J, Brodlie S, Brown J, Lobritto S, Martinez M. Bone Fractures in Children With Cholestatic Liver Disease May Mimic Those Seen in Child Abuse. Pediatr Emerg Care 2021; 37:e636-e639. [PMID: 30672906 DOI: 10.1097/pec.0000000000001740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Certain fractures in children are highly specific for child abuse. Metabolic bone disease frequently develops in patients with cholestatic liver disease (CLD); this can result in weakened bones and a predisposition to pathologic fractures. Fractures that occur in patients with rickets and osteopenia may mimic a bone response to inflicted injury, which in children raise the concern of child abuse. Here we report a series of 15 patients with CLD who developed pathologic fractures in the setting of metabolic bone disease. During initial evaluation, the caretakers of 5 of these 15 patients were reported to child protective services and investigated for child abuse. Pediatricians should be aware that children with CLD have an increased incidence of pathologic fractures, even after the cholestasis has resolved.
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Affiliation(s)
- Dana Goldner
- From the Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York
| | - Jennifer Vittorio
- From the Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York
| | | | - Jillian McGuire
- Department of Social Work, New York Presbyterian Hospital, New York, NY
| | - Susan Brodlie
- From the Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York
| | - Jocelyn Brown
- From the Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York
| | - Steven Lobritto
- From the Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York
| | - Mercedes Martinez
- From the Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York
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Krywanczyk A, Gilson T. Homicide by Unspecified Means: Cleveland 2008 to 2019. Am J Forensic Med Pathol 2021; 42:211-215. [PMID: 33491950 DOI: 10.1097/paf.0000000000000657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT The diagnosis homicide by unspecified means (HUM) is used to categorize deaths occurring under suspicious or criminal circumstances, but a specific cause of death cannot be identified. In 2010, Matshes and Lew (Am J Forensic Med Pathol. 2010;31(2):174-177) presented a HUM cases series, from which they derived 5 diagnostic criteria; however, the accuracy of these criteria has not been assessed.To identify a validation cohort, Cuyahoga County Medical Examiner's Office records were searched from 2008 to 2019 for cases certified as HUM. Thirteen cases were identified; on review, all cases fulfilled criteria 1, 4, and 5. Only 1 case had a potential anatomic cause of death identified (criterion 2).However, in 3 cases, toxicologic analyses could not be conducted because of skeletonization; in 2 cases, the decedents tested positive for cocaine/benzoylecgonine but were found in proximity to other victims for whom a specific violent cause of death was determined. By strict reading of criterion 3, these cases would have been excluded from the diagnosis of HUM. Perpetrators confessed to homicide in 7 cases, including the 5 cases that failed the toxicologic criterion. The 2010 diagnostic criteria are a reasonable foundation for the determination of HUM; modification of criterion 3 would provide improved flexibility based on clinical judgment.
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Affiliation(s)
- Alison Krywanczyk
- From the Division of Pathology and Laboratory Medicine, The Cleveland Clinic Foundation
| | - Thomas Gilson
- Cuyahoga County Medical Examiner's Office, Cleveland, OH
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Bloise S, Martucci V, Marcellino A, Mallardo S, Lubrano R. Possible Role of Thoracic Ultrasound in the Diagnostic Pathway of Infant Abuse in the Pediatric Emergency Department. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:1705-1707. [PMID: 33098578 DOI: 10.1002/jum.15546] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 09/29/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Silvia Bloise
- Department of Pediatrics, Sapienza University of Rome, Pediatric and Neonatology Unit, Ospedale Goretti Polo Pontino, Rome, Italy
| | - Vanessa Martucci
- Department of Pediatrics, Sapienza University of Rome, Pediatric and Neonatology Unit, Ospedale Goretti Polo Pontino, Rome, Italy
| | - Alessia Marcellino
- Department of Pediatrics, Sapienza University of Rome, Pediatric and Neonatology Unit, Ospedale Goretti Polo Pontino, Rome, Italy
| | - Saverio Mallardo
- Department of Pediatrics, Sapienza University of Rome, Pediatric and Neonatology Unit, Ospedale Goretti Polo Pontino, Rome, Italy
| | - Riccardo Lubrano
- Department of Pediatrics, Sapienza University of Rome, Pediatric and Neonatology Unit, Ospedale Goretti Polo Pontino, Rome, Italy
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Is a Parry Fracture-An Isolated Fracture of the Ulnar Shaft-Associated with the Probability of Abuse in Children between 2 and 16 Years Old? CHILDREN-BASEL 2021; 8:children8080650. [PMID: 34438541 PMCID: PMC8394848 DOI: 10.3390/children8080650] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/16/2021] [Accepted: 07/26/2021] [Indexed: 11/17/2022]
Abstract
A parry fracture is an isolated fracture of the ulnar shaft. It occurs when the ulna receives the full force of an impact when the forearm is raised to protect the face. The aim of this study is to assess a possible association between a parry fracture and the probability of abuse in children. In this retrospective, observational, multicenter study, we identified patients between 2 and 16 years old who had been treated for an isolated ulnar shaft fracture. Patient characteristics were registered, anonymized radiographs were rated, and charts were screened for referral to a child protective team. A total of 36 patients were analyzed. As no referrals were registered during follow-up, the primary outcome was changed to a perpendicular force as trauma mechanism. Univariable regression analysis and independent t-test both showed no significant association between patient factors or radiographic classification, and the reported trauma mechanism. We were unable to determine an association between a parry fracture and the probability of abuse. Since trauma mechanism does have a biomechanical effect on the fracture type, we would advise that a very clear reconstruction (and documentation) of the trauma mechanism should be established when a parry fracture is identified on radiographs.
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