A Practical Guide to Differentiating Abusive From Accidental Fractures: An Injury Plausibility Approach

Factors associated with decisions to refer possible abusive head trauma to a hospital-based child protection team in Aotearoa New Zealand

BACKGROUND

Aotearoa New Zealand has a high incidence of abusive head trauma (AHT) and a national children's hospital with an established multi-disciplinary child protection team (CPT). Staff concerned about possible AHT are expected to refer to the CPT, but there has been no research into the factors which might influence those referral decisions.

OBJECTIVE

To identify factors associated with decisions to refer head-injured children to the CPT, and to assess whether those factors are consistent with the literature.

PARTICIPANTS AND SETTING

All children <5 years old admitted from 2010 to 2019 with skull fracture or intracranial injury.

METHODS

Retrospective review comparing 25 variables in cases referred and not referred. Multivariable analysis estimated the independent role of each variable and modelled their combined contribution to decisions to refer. The area under the receiver operator characteristic curve (AUROC) and 95 % CI were used to describe performance of the model.

RESULTS

Of 631 head-injured children, 265 (42 %) were referred and 121 (19 %) diagnosed as AHT/undetermined. Variables associated with referral decisions were age < 1 year, p = .0001; injury inconsistent with the history, p < .0001; certain categories of history (motor vehicle accident, no history, history of abuse, fall <1 m, blunt force and penetrating trauma), p < .0001; delayed presentation, p < .0001; past history of injury, p = .0001; social/behavioral concerns, p < .0001 and subdural hemorrhage, p = .01. The AUROC was 0.95 (95 % CI 0.93, 0.97).

CONCLUSIONS

Factors associated with referral are generally consistent with the literature. The percentage referred seems justified given the number diagnosed as AHT/undetermined.

Is a Parry Fracture-An Isolated Fracture of the Ulnar Shaft-Associated with the Probability of Abuse in Children between 2 and 16 Years Old?

A parry fracture is an isolated fracture of the ulnar shaft. It occurs when the ulna receives the full force of an impact when the forearm is raised to protect the face. The aim of this study is to assess a possible association between a parry fracture and the probability of abuse in children. In this retrospective, observational, multicenter study, we identified patients between 2 and 16 years old who had been treated for an isolated ulnar shaft fracture. Patient characteristics were registered, anonymized radiographs were rated, and charts were screened for referral to a child protective team. A total of 36 patients were analyzed. As no referrals were registered during follow-up, the primary outcome was changed to a perpendicular force as trauma mechanism. Univariable regression analysis and independent t-test both showed no significant association between patient factors or radiographic classification, and the reported trauma mechanism. We were unable to determine an association between a parry fracture and the probability of abuse. Since trauma mechanism does have a biomechanical effect on the fracture type, we would advise that a very clear reconstruction (and documentation) of the trauma mechanism should be established when a parry fracture is identified on radiographs.

Recording Risk Factors of Physical Abuse in Children Younger Than 36 Months With Bone Fractures: A 12-Years Retrospective Study in an Italian General Hospital Emergency Room

Skeletal fractures (SFs) are very common in pediatrics. In some cases, they are secondary to child abuse. Differentiation of accidental from non-accidental fractures (NAFs) is essential as in abused children risk of further injuries leading to severe clinical problems and death is significant. Main objectives of this study were to evaluate the characteristics of SFs of children ≤3 years of age presenting to the Emergency Room (ER) of a Children's Teaching Hospital over a 12-year period and the attention paid by ER physicians to the identification of the indicators that increase suspicion of NAF and that suggest referring of the patient to the child protection agencies. This is a descriptive, retrospective study of the medical records of all the pediatric patients ≤ 36 months of age admitted to the ER of the Azienda Ospedaliera Santa Maria della Misericordia, University of Perugia, Perugia, Italy, for radiological documented SFs between January 1, 2004, and March 31, 2016. Available information was used to evaluate whether indicators of possible child abuse were documented by the ER staff and whether diagnosis of potential abuse was followed by further screening or referral to child protection agencies. During the study period, 11,136 accesses of the ER by children younger than 36 months were documented, among whom 417 presented long bone or skull fractures. Skull fractures were significantly more common among children <12 months of age (p = 0.001), whereas radius/ulna and humerus fractures were diagnosed significantly more frequently in children 12-36 months of age (p = 0.036 and p = 0.022, respectively). Recorded medical history was considered inadequate in 255 (61.2%) cases with no difference related to patient's age. Our study showed that the majority of charts in case of SFs were found to contain inadequate documentation to explain causes at the heart of the fractures and, therefore, to rule out any inflicted trauma. The development of specific referral guidelines, along with the continuous education and training of health professionals, as well as the preparation of structured medical forms, are essential measures to activate in order to improve the referral of children from the ER to child protection agencies.

Keeping an Open Mind: Cognitive Bias in the Evaluation of an Infant with Posterior-Lateral Rib Fractures

A four-month-old former premature male is incidentally found to have posterior-lateral rib fractures during evaluation of a febrile illness. This finding led to the initiation of a workup for nonaccidental trauma. A thorough history and physical exam ultimately led to the diagnosis, which was not related to abuse. This case highlights a rare sequela of patent ductus arteriosus repair, cautions medical teams to remain aware of how cognitive bias can affect diagnostic decision-making, and emphasizes the importance of a thorough history, physical exam, and medical record review in cases of suspected nonaccidental trauma.

Understanding forearm fractures in young children: Abuse or not abuse?

This retrospective study describes the characteristics and mechanisms of forearm fractures in children <18 months adding to the evidence-base about forearm fractures. It also examines which features of forearm fractures in young children may help discriminate between abusive and noninflicted injuries. Electronic medical records were reviewed for eligible patients evaluated between September 1, 2007 and January 1, 2012 at two children's hospitals in Chicago, IL. The main outcome measures were the type of fracture and the etiology of the fracture (abuse versus not abuse). The 135 included patients sustained 216 forearm fractures. Most were buckle (57%) or transverse (26%). Child protection teams evaluated 47 (35%) of the patients and diagnosed 11 (23%) as having fractures caused by abuse. Children with abusive versus non-inflicted injuries had significant differences in age (median age 7 versus 12 months), race, and presence of additional injuries. Children with abusive forearm fractures often presented without an explanation or a changing history for the injury. Children with non-inflicted forearm fractures often presented after a fall. No particular type of forearm fracture was specific for child abuse. Any forearm fracture in a young child should be evaluated with special attention to the details of the history and the presence of other injuries. Young age, additional injuries, and an absent or inconsistent explanation should increase concern that the fracture was caused by child abuse.