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Fractures in young children. Distinguishing child abuse from unintentional injuries
J M Leventhal1, S A Thomas, N S Rosenfield
1Department of Pediatrics, Yale University School of Medicine, New Haven, Conn. 06510.
Insights
Child abuse is common in young children with fractures. Specific fracture types and circumstances, like reported falls or injuries in infants, can help distinguish abuse from unintentional injuries.
Area of Science:
- Pediatric radiology
- Child abuse detection
- Forensic pediatrics
Background:
- Distinguishing child abuse from unintentional injuries in young children with fractures is a critical diagnostic challenge.
- Fracture patterns in pediatric patients can offer vital clues to the mechanism of injury.
Purpose of the Study:
- To identify specific fracture features in children under three years old that aid in differentiating child abuse from accidental trauma.
- To provide empirical evidence for clinicians and radiologists in evaluating serious pediatric injuries.
Main Methods:
- A case series design was employed, analyzing fractures in children under three years old over a five-year period.
- Fractures were categorized using predefined criteria and consensus from clinicians and pediatric radiologists on a seven-point scale.
- Data included caretaker reports on the event, injury severity, fracture location, and age of the child.
Main Results:
- Of 253 fractures in 215 children, 24.2% were attributed to abuse and 67.4% to unintentional injuries.
- Fractures likely due to abuse included those in infants (<1 year) with specific long bone fractures (radius/ulna, tibia/fibula, femur) or humerus midshaft/metaphyseal fractures.
- Reported events involving behavioral changes without an accident or minor falls with severe injuries were also associated with abuse.
Conclusions:
- Child abuse is a significant cause of fractures in young children.
- Specific fracture characteristics and associated circumstances are valuable in distinguishing abuse from unintentional injuries.
- This study provides evidence to support accurate examination of children with fractures potentially related to abuse.
Objective:
To determine features of fractures in young children that would be helpful in distinguishing child abuse from unintentional injuries.
Design:
Case series.
Setting:
Pediatric Services of Yale-New Haven (Conn) Hospital (a tertiary care center).
Patients:
Consecutive children who were less than 3 years of age and who were examined for a fracture from January 1979 through December 1983 were identified from the daily logs of the emergency department or the hospital's child abuse registry.
Outcome Measure:
Each case was rated, by means of predefined criteria and a consensus of two clinicians and two pediatric radiologists, on a seven-point scale from "definite child abuse" to "definite unintentional injury." A middle rating of "unknown" was used if there was not enough information to reach a consensus.
Results:
Of the 253 fractures in 215 children that were identified, we categorized 24.2% as abuse, 8.4% as unknown, and 67.4% as unintentional injuries. Fractures that were considered likely due to abuse were (1) fractures in children whose caretakers reported either a change in the child's behavior, but no accidental event, or a minor fall, but the injury was more severe than expected; (2) fractures of the radius/ulna, tibia/fibula, or femur in children less than 1 year of age; or (3) midshaft or metaphyseal fractures of the humerus. Linear fractures of the parietal bone were the most common skull fractures, whether due to abuse or unintentional injuries.
Conclusion:
In young children with fractures, child abuse is common. By comparing fractures due to abuse and those due to unintentional injuries, we obtained empiric evidence to help clinicians and radiologists correctly examine children with such serious injuries.