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What factors affect the identification and reporting of child abuse-related fractures?
Wendy G Lane1, Howard Dubowitz
1Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD 21201, USA. wlane@epi.umaryland.edu
Insights
Orthopaedic surgeons show moderate skill in identifying child abuse fractures but need more training. Decisions were influenced by socioeconomic status, not race, highlighting potential biases in fracture assessments.
Area of Science:
- Orthopaedic Surgery
- Pediatric Medicine
- Child Abuse Forensics
Background:
- Child abuse, particularly involving fractures, presents a significant challenge in the United States.
- Orthopaedic surgeons play a critical role in the identification and reporting of suspected child abuse fractures to child protective services (CPS).
Purpose of the Study:
- To evaluate orthopaedic surgeons' proficiency in differentiating abuse-related fractures from non-inflicted injuries.
- To assess the accuracy of their decisions regarding reporting to child protective services.
- To determine if orthopaedist training, or the race and socioeconomic status of injured children, influence these critical decisions.
Main Methods:
- A questionnaire with 10 case vignettes was developed and mailed to 974 US orthopaedists.
- Respondents assessed fracture likelihood of abuse and necessity of reporting to child protective services.
- Two questionnaire versions were used, varying the race and socioeconomic status of the vignette families to examine potential biases.
Main Results:
- Respondents achieved average scores of 79% for correct diagnoses and 73% for appropriate reporting decisions.
- Pediatric orthopaedists demonstrated higher accuracy in identifying abuse-related fractures (82% vs. 73%) and reporting (76% vs. 66%) compared to general orthopaedists.
- Both groups struggled with distinguishing abuse-related from non-inflicted long-bone fractures in infants and toddlers; reporting decisions were influenced by socioeconomic status but not race.
Conclusions:
- Additional specialized training is necessary for orthopaedists in recognizing abuse-related long-bone fractures.
- Orthopaedists must be aware of and mitigate potential biases related to socioeconomic status when evaluating children for abuse.
- Improving diagnostic and reporting accuracy is crucial for protecting children from abuse.
Abstract:
Child abuse is a serious problem in the United States. Because orthopaedic surgeons are responsible for identifying and reporting suspicious fractures to child protective services, we asked two primary questions: (1) How skilled are orthopaedists in distinguishing abuse-related from noninflicted fractures and making appropriate child protective services reports?; and (2) Are decisions influenced by orthopaedist training or by the race or socioeconomic status of injured children? We developed and mailed a questionnaire containing 10 case vignettes to 974 US orthopaedists. Respondents assessed the likelihood of abuse and need to report to child protective services. Two versions of the questionnaire differed by the race and socioeconomic status of vignette families. Average respondent scores were 79% for correct diagnoses and 73% for correct reporting decisions. Pediatric orthopaedists had higher adjusted scores for identifying abuse-related versus noninflicted injuries (82% versus 73%) and for appropriately reporting to child protective services (76% versus 66%) compared with general orthopaedists. Both groups had difficulty distinguishing abuse-related from noninflicted long-bone fractures in infants and toddlers. We found no differences in appropriate identification or reporting of fractures by race but did find differences by social class. Additional training in identifying abuse-related long-bone fractures appears necessary. Orthopaedists should consider the potential for bias when assessing children with fractures for possible abuse.
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