Skeletal Survey Yield in Young Children with Femur Fractures

Fractures are common in children, and it can be difficult to distinguish unintentional injuries from child abuse.

We describe circumstances of injury, prevalence of suspicion for physical abuse, and use of imaging to identify additional occult fractures in young children with femur fractures.

We reviewed the medical records for children younger than 48 months old with femur fractures treated at a pediatric referral hospital (2011-2013). We abstracted age, ambulation, injury circumstances, bruising, head trauma, additional fractures, and determination of injury suspicious for abuse.

In 22 of 127 (17%) children with femur fractures, there was strong suspicion for physical abuse. Infants ≤ 12 months old accounted for 19 of 22 (86%) of those with suspicious injuries. In 2 of 22 (9%) with suspected abuse, the child could walk independently. In 8 of 22 (36%) with suspicious injuries, an injury event was reported as directly witnessed versus 50 of 105 (48%) of the unintentional injuries. Six of 22 (27%) with suspicious injuries had bruises versus 11 of 105 (10%) with unintentional injuries (χ², p < 0.03). Four of 22 (18%) children with suspicious injuries had head trauma, versus 0 of 105 with unintentional injuries. Of the 8 with occult fractures identified on a skeletal survey (designated suspicious for abuse), all were ≤ 12 months old and none were walking independently.

Most children with femur fractures suspicious for abuse were ≤ 12 months old and not walking independently. Skeletal surveys identified additional fractures in 7% of children, and were useful in the forensic evaluation of non-ambulatory children ≤ 12 months old.