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Published on: April 18, 2011
Femur fractures in the pediatric population: abuse or accidental trauma?
Keith Baldwin1, Nirav K Pandya, Hayley Wolfgruber
1Department of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Insights
Distinguishing child abuse from accidental femur fractures in young children is crucial. A predictive model using history, physical exam, prior injuries, and age can help identify abuse in pediatric femur fractures.
Area of Science:
- Pediatric Orthopaedics
- Child Abuse Detection
- Forensic Medicine
Background:
- Child abuse poses significant risks to children's health.
- Orthopaedic specialists encounter bony injuries when child abuse is suspected.
- Differentiating abuse from accidental trauma is challenging, relying heavily on clinical suspicion.
Purpose of the Study:
- To determine if accidental femur fractures in children under 4 can be distinguished from abuse.
- To evaluate the utility of history, physical examination, radiographic findings, and age as distinguishing factors.
Main Methods:
- Retrospective review of institutional SCAN (Suspected Child Abuse and Neglect) and trauma databases.
- Comparison of 70 patients with femur fractures due to abuse versus 139 with fractures from accidental trauma.
- Analysis of risk factors including suspicious history, prior injury evidence, and patient age.
Main Results:
- Key risk factors for abuse included suspicious history, physical/radiographic evidence of prior injury, and age under 18 months.
- The likelihood of abuse increased significantly with the number of risk factors present: 4% (0 factors), 29% (1 factor), 87% (2 factors), and 92% (3 factors).
Conclusions:
- A predictive model incorporating specific risk factors can aid clinicians in identifying femur fractures resulting from abuse in young children.
- This model can guide clinical judgment and facilitate timely referral to social services in emergency room settings.
Background:
Child abuse represents a serious threat to the health and well-being of the pediatric population. Orthopaedic specialists will often become involved when child abuse is suspected as a result of the presence of bony injury. Distinguishing abuse from accidental trauma can be difficult and is often based on clinical suspicion.
Questions/Purposes:
We sought to determine whether accidental femur fractures in pediatric patients younger than age 4 could be distinguished from child abuse using a combination of presumed risk factors from the history, physical examination findings, radiographic findings, and age.
Methods:
We searched our institution's SCAN (Suspected Child Abuse and Neglect) and trauma databases. We identified 70 patients in whom the etiology of their femur fracture was abuse and compared that group with 139 patients who had a femur fracture in whom accidental trauma was the etiology.
Results:
A history suspicious for abuse, physical or radiographic evidence of prior injury, and age younger than 18 months were risk factors for abuse. Patients with no risk factors had a 4% chance, patients with one risk factor had a 29% chance, patients with two risk factors had an 87% chance, and patients with all three risk factors had a 92% chance of their femur fracture being a result of abuse.
Conclusions:
Clinicians can use this predictive model to guide judgment and referral to social services when seeing femur fractures in very young children in the emergency room.
Level Of Evidence:
Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
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