Identifying non-accidental fractures in children aged <2 years

Findings Associated With Nonaccidental Trauma in Children With Isolated Femoral Diaphyseal Fractures

BACKGROUND

Pediatric patients with isolated femoral diaphyseal fractures are difficult to assess for nonaccidental trauma (NAT). The purpose of this study was to determine (1) if there are any demographic features of isolated femoral diaphyseal fractures associated with suspected NAT and (2) if there are clinical signs associated with isolated femoral diaphyseal fractures associated with suspected NAT.

METHODS

All patients with femoral diaphyseal fractures from January 2010 to June 2018 were reviewed. We included patients younger than 4 years old with isolated femoral diaphyseal fractures. We excluded patients 4 years old and older, polytraumas, motor vehicle collisions, and patients with altered bone biology. Diagnosis of suspected NAT was determined by review of a documented social work assessment. We recorded fracture characteristics including location along femur as well as fracture pattern and presence of associated findings on NAT workup including the presence of retinal hemorrhage, subdural hematoma, evidence of prior fracture, or cutaneous lesions. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of these associated findings were calculated.

RESULTS

Totally, 144 patients met the inclusion criteria. Social work was consulted on 50 patients (35%). Suspected NAT was diagnosed in 27 patients (19%). The average age of patients with suspected NAT was 0.82 and 2.25 years in patients without NAT ( P <0.01). The rate and type of skin lesions present on exam were not different between the 2 groups. Patients with suspected NAT had no findings of retinal hemorrhage or subdural hematoma, but 5 of 27 patients (19%) had evidence of prior fracture on skeletal survey. The sensitivities of retinal hemorrhage, subdural, and skeletal survey were 0%, 0%, and 19% and the specificities of all were 100%. The NPVs were 39%, 27%, and 63%, respectively. The PPV of skeletal survey was 100%. Since there were no patients in this study with positive findings of retinal hemorrhage or subdural hematoma, the PPV for these could not be assessed.

CONCLUSIONS

In the current study, signs of NAT such as skin lesions, retinal hemorrhage, subdural hematoma, and evidence of prior fracture on skeletal survey may not be helpful to diagnosis suspected NAT in patients with an isolated femoral diaphyseal fracture.

LEVEL OF EVIDENCE

Level III-diagnostic study.

Pediatric skeletal injuries in emergency department; an alarm of child maltreatment in Egypt: A cross-sectional study

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.

Investigating the Determinants of Nonaccidental Trauma Evaluation in Pediatric Femur Fractures

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.

Humeral shaft fractures: a practical guide to assessment and management

Fractures of the humeral shaft represent roughly 5% of all fractures. They occur in an approximate bimodal distribution, typically affecting young adults following trauma and older females after low energy falls in the presence of osteoporosis. Humeral shaft fractures are associated with pain, temporary disability and a reduced quality of life for the duration of treatment. Treatment goals are directed towards achieving and maintaining a fracture environment conducive to healing, pain relief and early restoration of function. While most humeral shaft fractures are conservatively managed, operative management is indicated in certain circumstances. This article provides an overview of these fractures, including their initial management approach and definitive treatment.

The diagnosis and management of abusive head injuries in infancy in Egypt

Child death owed to abuse and negligence is not uncommon, and its real incidence is unknown. The most common cause of fatal child abuse is head trauma. Abusive head injuries (AHI) most often involve brain injury of infants and young children. The outcomes of AHI vary from complete recovery to severe brain damage and death. This article highlights the diagnosis and management of AHI in infancy in Egypt, with a special focus on the social, medical, and legal aspects. The authors emphasize the importance of reporting cases suspected of AHI to the relevant authorities; this will guard against the recurrence of abuse to the child and will have a positive impact on the community.

Factors Associated With Referral of Children With a Femur Fracture to a Social Worker by an Orthopedist for Suspected Child Abuse

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.

Nonaccidental Trauma in Pediatric Elbow Fractures: When You Should Be Worried

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.

Rate of orthopedic resident and medical student recognition of nonaccidental trauma: a pilot study

The purpose of this study was to evaluate the efficacy and accuracy of mandated reporters to identify child abuse in children presenting with fractures. An Institutional Review Board approved survey-based study between January 2017 and December 2017 was conducted at a tertiary care academic medical center. 10 cases were combined to create one survey. Each case had information on presentation history, radiographic data, and social history. This study assesses the ability of 13 orthopedic residents and 11 medical students to diagnose child abuse. Participants had the option to explain their reasoning for a given case. To evaluate decision-making reasoning, we split responses into three cohorts, encompassing objective evidence, subjective evidence, or social evidence. Twenty-four participants completed the survey; 203 out of 240 (85%) included the rationale for the diagnosis of child abuse. The observed diagnostic odds ratio was 0.83 for medical students, 0.93 for junior residents, and 0.96 for senior residents. There was no statistically significant difference in diagnosing child abuse between a participant's level of experience, age, or whether participants had their own children. Participants who used more than one source of evidence were significantly more likely to make the correct diagnosis (P = 0.013). Participant decisions were no more accurate than a coin toss. The use of several data sources led to increased diagnostic accuracy. There is low accuracy in correctly diagnosing child abuse in our cohort of mandated reporters. Participants who highlighted using several sources of evidence were more likely to diagnose child abuse accurately.

Practice Variation in Use of Neuroimaging Among Infants With Concern for Abuse Treated in Children's Hospitals

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.

A review of current imaging techniques used for the detection of occult bony fractures in young children suspected of sustaining non-accidental injury

Non-accidental injuries remain a leading cause of preventable morbidity and mortality in young children. The accurate identification of the full spectrum of injuries in children presenting with suspected abuse is essential to ensure the appropriate protective intervention is taken. The identification of occult bone fractures in this cohort is important as it raises the level of concern about the mechanism of injury and maintaining the child's safety. Radiographic imaging remains the modality of choice for skeletal assessment; however, current studies report concerns regarding the ability of radiographs to detect certain fractures in the acute stage. As such, alternative modalities for the detection of fractures have been proposed. This article reviews the current literature regarding fracture detectability and radiation dose burden of imaging modalities currently used for the assessment of occult bony injury in young children in whom non-accidental injury is suspected.

Overview of the contemporary management of supracondylar humeral fractures in children

PURPOSE

Supracondylar fractures are common injuries accounting for approximately 15% of all fractures in children with a large body of literature on this subject.

METHODS

 This article critically appraises the available evidence to provide an overview of the treatment options including the role and timing of surgery, the geometry of wire fixation and the management of nerve and arterial injury.

CONCLUSION

 Management decisions are based on a number of considerations particularly fracture stability. Closed reduction and percutaneous K-wire stabilisation are commonly recommended for an unstable displaced fracture. These techniques are however associated with the potential for iatrogenic neurological injury. Vascular injury is also rare but must be recognised and treated promptly to avoid significant permanent morbidity.

Lyme Disease Misinterpreted as Child Abuse

Child abuse is one of the most common causes for child fatality in the United States. Inaccurate reporting of child abuse combined with scarcity of resources for child abuse evaluations can lead to unintended consequences for children and their families. The differential diagnosis of child abuse is varied. To our knowledge, there are no reports in the literature on Lyme disease mimicking child abuse. The current study presents the case of a child from an endemic area for Lyme disease presenting with skin bruising, fracture, and swollen knee. The child was reported for child abuse by the pediatrician and then referred to the orthopaedic surgeon for fracture care.

Pediatric Nonaccidental Trauma: Experience at a Level 1 Trauma Center

Introduction

Pediatric nonaccidental trauma (NAT) is difficult to diagnose. Several isolated injuries in NAT could happen in the setting of accidental trauma (AT), and having a high index of suspicion is important to correctly identify abuse. NAT has a significant mortality rate if the sentinel event is not adequately diagnosed, and the infant is not separated from the perpetrator. Level 1 pediatric trauma centers (PTC) see a significant number of NAT. We evaluated the injury patterns of NAT admissions at our level 1 PTC.

Methods

Retrospective analysis of all cases of NAT for children under the age of two admitted at an ACS level 1 pediatric trauma center between the years of 2016 and 2018. Charts were queried for demographic data, injury patterns, mortality, and disposition. Correlation between disposition status and injury patterns was performed. The Fisher Exact test and student t-test were used to study the significance of differences in categorical and continuous data, respectively.

Results

32/91 (35%) trauma patients under the age of two years were diagnosed as NAT in the three-year study period. 21/32 (39%) male and 11/26 (42%) female admissions were confirmed NAT (p = NS). 20 were under 1 year of age, and 12 were aged between 1 and 2 years (p = NS). 13 (41%) were Caucasian, 6 (19%) were Hispanic/Latino, 11 (34%) were Black, and 2(6%) were of unknown ethnicity (p = NS). Facial, torso, lower extremity, retinal, and internal organ injury were significantly more common with NAT. Medicaid coverage was noted in 31/32 (97%) NAT patients. 20/32 (62.5%) patients were legally displaced as a result of the NAT.

Conclusion

1/3^rd of all admissions at a pediatric level 1 trauma center were identified as NAT. A high index of suspicion is necessary to not miss NAT, as injury patterns are variable. Nearly 1/3^rd of all victims go back to the same environment where they sustained NAT increasing their susceptibility to future NAT.

The Role of the Orthopaedic Surgeon in the Identification and Management of Nonaccidental Trauma

Nonaccidental trauma (NAT) has short- and long-term effects on the patient. The importance of identification and management of injuries related to NAT can be vital to the disruption of patterns of abuse and can ultimately save lives. The purpose of this review is to educate the orthopaedic surgeon as the frontline provider in the treatment of these patients. Understanding the risk factors for abuse, sentinel signs on clinical examination, and questionable fracture patterns related to NAT enables providers to better identify and address children at risk of abuse or neglect. Equally as important, understanding pathologic states that can mimic NAT allows the orthopaedic surgeon the tools necessary to address all patients with multiple and/or unexplained fractures. Understanding the legal expectations and protections for practicing orthopaedic surgeons as mandated reporters and the importance of a multidisciplinary approach to intervention in these settings will improve patient experiences and outcomes.

Impact of Child Abuse Clinical Pathways on Skeletal Survey Performance in High-Risk Infants

OBJECTIVE

We sought: 1) to examine the association between the presence of a child abuse pathway and the odds of skeletal survey performance in infants with injuries associated with high risk of abuse and 2) to determine whether pathway presence decreased disparities in skeletal survey performance.‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬ METHODS: In this retrospective study of children <1 year diagnosed with injuries associated with high risk of abuse at hospitals in the Pediatric Hospital Information System, information regarding the presence of a child abuse pathway was collected via survey. We examined whether the presence of a child abuse pathway was associated with the odds of obtaining a skeletal survey, adjusting for patient-level factors.‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬ RESULTS: Among 2085 included cases 55% were male, 69% had public insurance, and 64% were white. Fifty-eight percent presented to a hospital when a pathway was present. Skeletal surveys were performed in 86% of children between 0 and 5 months and 73% of children 6-11 months. In our regression model, adjusted for covariates (age, race, insurance, injury) the presence of a child abuse pathway in a hospital was associated with greater odds of skeletal survey performance (odds ratio [OR], 1.46, 95% confidence interval [CI], 1.02-2.08). Children with public insurance had greater odds of receiving a skeletal survey (OR 2.75, 95% CI 2.11-3.52) despite presence of pathway.‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬ CONCLUSIONS: When a child abuse clinical pathway was present, children with injuries associated with a high risk of abuse had a greater odds of receiving a skeletal survey. Differences in skeletal survey performance exist between infants with public vs. private insurance regardless of a pathway.

Infantile Supracondylar Humeral Fractures (Patients Less Than Two Years of Age): Twice as Common in Females and a High Rate of Malunion with Lateral Column-Only Fixation

BACKGROUND

The age range for supracondylar humeral fractures spans from 1 to 14 years of age; most published studies have analyzed patients as non-age-segregated cohorts. Some isolated studies focused on the upper age range, demonstrating a male predominance and more severe fractures. The purpose of the current study was to analyze a large cohort of patients with surgically treated supracondylar humeral fractures at the low end of the age range (<2 years of age).

METHODS

Patients <2 years of age were identified from surgical billing records. Pin constructs were categorized as lateral column-only fixation or medial and lateral column fixation. All patients were followed through fracture-healing. Substantial loss of reduction was defined as a Baumann angle that changed ≥10° between surgery and healing or as a lateral rotation percentage (i.e., Gordon index) of ≥50% at the time of healing. The Fisher exact test was used for statistical analysis.

RESULTS

One hundred and three patients met our inclusion criteria. There were 69 female and 34 male patients (a 2:1 female-to-male ratio). Two patients did not have adequate follow-up radiographs. Of the 46 patients with bicolumnar fixation, 5 (11%) demonstrated loss of reduction compared with 20 (36%) of 55 patients with lateral column-only fixation. This difference between the groups was significant (p = 0.005). The group with lateral column-only fixation had 4.7-times-higher odds of loss of reduction (95% confidence interval, 1.6 to 13.8). A subset of patients had in-cast imaging that allowed calculation of the posterior sagittal cast index (a measure of cast fit). Eight of 15 patients who had a posterior sagittal cast index of ≥0.20 experienced loss of reduction, while only 1 of 19 patients with a cast index value of <0.20 had loss of reduction (p = 0.004).

CONCLUSIONS

Supracondylar humeral fractures were twice as common in females in this very young cohort. We also found a nearly 5-times-higher odds of loss of reduction when fracture fixation was of the lateral column only.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Characteristics of Nonaccidental Fractures in Abused Children in Riyadh, Saudi Arabia

Background:

Child abuse is a major problem globally. Nonaccidental fractures are the second most common injury among physically abused children; however, there is a lack of studies describing the characteristics of nonaccidental fractures in Saudi Arabia.

Objectives:

The objective of this study was to determine the characteristics of nonaccidental fractures among abused children in Riyadh, Saudi Arabia, using radiography.

Materials and Methods:

This retrospective study analyzed the data and radiographs of all nonaccidental fracture cases in children (aged ≤14 years) registered in the National Family Safety Program Registry at King Abdulaziz Medical City, Riyadh, between 2009 and 2015.

Results:

A total of 1512 cases of child abuse were found in the National Family Safety Program Registry database from Riyadh city. From these, 103 fractures were identified; however, radiographs were available for only 70 fractures from 56 children. Of these, 33 (59%) were boys, and 25 (45%) were aged 1–5 years. In terms of the type of abuse, neglect was more common than physical abuse (52% vs. 45%). History of injury was identified in 75% (42) of the cases, of which fall accounted for about 55% (23). Nearly 79% of children presented with a single bone fracture, while 21% had multiple bone fractures. The most common sites of fractures were skull (40%), upper limbs (31%) and lower limbs (29%). The most common fracture pattern was transverse fractures (48%), and it was mainly diagnosed in skull fractures (51%).

Conclusions:

This study found that in Riyadh, Saudi Arabia, neglect is the most common cause of nonaccidental fractures, abusive head trauma is the most commonly associated injury and transverse fracture is the primary pattern of fracture in abused children. Notably, as most children experienced a single-bone fracture, the authors recommend clinicians to lower their threshold of considering abuse even in cases with an isolated fracture.

The Risk of Assuming Abuse in an Infant with an Isolated Metaphyseal Lesion: A Case Report

CASE

The classic metaphyseal lesion, or corner fracture, is considered a strong indicator of nonaccidental trauma. In the present case, the parents brought their 8-month-old boy to a community hospital after he stopped crawling on the right leg. A knee radiograph demonstrated an isolated metaphyseal lesion, which prompted concern for child abuse. The patient was transferred to the nearest academic medical center; the pediatric radiology expert in child abuse determined that the lesion was a normal variant and not the result of abuse.

CONCLUSION

An isolated metaphyseal lesion is not pathognomonic for child abuse, and a thoughtful differential diagnosis should be considered.

Abusive fracture incidence over three decades at a level 1 pediatric trauma center

Few studies have examined the incidence of abusive fractures in children. Only one study to date, from a single pediatric trauma center,has reported on the incidence of abusive fractures over time. That study showed a decrease in abusive fractures over a 24-year period. Our objective for this current study was to compare these published data with recent data from this same trauma center, allowing for a detailed comparison of the incidence of abusive fractures over a 30-year period. We included children <36months of age who presented to the emergency department of a level 1 pediatric trauma center (2007-2010) with≥1 fracture. Six experts from 3 different fields rated each case on the likelihood the fracture(s) was caused by abuse using an established 7- point scale, and a consensus rating was agreed upon for each case. The incidence of abusive fractures was calculated per 10,000 children <36months of age living in the geographic region and per 10,000 ED visits and was compared to previously published data for three prior time periods (1979-1983, 1991-1994, and 1999-2002) at the same pediatric trauma center. From 2007-2010, 551 children were identified, including 31 children who were rated as abused. The incidence of a child presenting with an abusive fracture in the county per year was 2.7/10,000 children <36months of age. The previous three time periods showed a countywide incidence of 3.2/10,000 (1979-1983), 1.7/10,000 (1991-1994), and 2.0/10,000 (1999-2002) (p for trend 0.34). The incidence per ED visit was 2.5/10,000 in the recent time period compared to 6.0/10,000 (1979-1983), 3.4/10,000 (1991-1994), and 2.5/10,000 (1999-2002) (p for trend <0.001). In this single institution review of fractures in children <36months of age, the incidence of abusive fractures has remained relatively constant over a 30-year period.

Corner fracture type spondylometaphyseal dysplasia: Overlap with type II collagenopathies

Spondylometaphyseal dysplasia (SMD) corner fracture type (also known as SMD "Sutcliffe" type, MIM 184255) is a rare skeletal dysplasia that presents with mild to moderate short stature, developmental coxa vara, mild platyspondyly, corner fracture-like lesions, and metaphyseal abnormalities with sparing of the epiphyses. The molecular basis for this disorder has yet to be clarified. We describe two patients with SMD corner fracture type and heterozygous pathogenic variants in COL2A1. These two cases together with a third case of SMD corner fracture type with a heterozygous COL2A1 pathogenic variant previously described suggest that this disorder overlaps with type II collagenopathies. The finding of one of the pathogenic variants in a previously reported case of spondyloepimetaphyseal dysplasia (SEMD) Strudwick type and the significant clinical similarity suggest an overlap between SMD corner fracture and SEMD Strudwick types. © 2016 Wiley Periodicals, Inc.