Soft tissue swelling with fractures: abuse versus nonintentional

Child abuse: review of the literature

Non-accidental injuries in children are an important cause of morbidity and mortality in this population. Fractures are the second most common clinical manifestation of child abuse. The fracture of the femur is associated in more than 60% of child abuse in children younger than 3 years. The objective was to review the literature on child abuse in the major databases and report a rare case of bilateral subtrochanteric femur fractures associated with unilaterall humeral fracture in a 28-day newborn. The orthopedic surgeon is often the first physician to evaluate these children, so a high degree of suspicion, and a physical examination and a detailed clinical history is mandatory when evaluating a newborn with musculoskeletal injuries.

Delayed identification of pediatric abuse-related fractures

OBJECTIVES

Because physicians may have difficulty distinguishing accidental fractures from those that are caused by abuse, abusive fractures may be at risk for delayed recognition; therefore, the primary objective of this study was to determine how frequently abusive fractures were missed by physicians during previous examinations. A secondary objective was to determine clinical predictors that are associated with unrecognized abuse.

METHODS

Children who were younger than 3 years and presented to a large academic children's hospital from January 1993 to December 2007 and received a diagnosis of abusive fractures by a multidisciplinary child protective team were included in this retrospective review. The main outcome measures included the proportion of children who had abusive fractures and had at least 1 previous physician visit with diagnosis of abuse not identified and predictors that were independently associated with missed abuse.

RESULTS

Of 258 patients with abusive fractures, 54 (20.9%) had at least 1 previous physician visit at which abuse was missed. The median time to correct diagnosis from the first visit was 8 days (minimum: 1; maximum: 160). Independent predictors of missed abuse were male gender, extremity versus axially located fracture, and presentation to a primary care setting versus pediatric emergency department or to a general versus pediatric emergency department.

CONCLUSIONS

One fifth of children with abuse-related fractures are missed during the initial medical visit. In particular, boys who present to a primary care or a general emergency department setting with an extremity fracture are at a particularly high risk for delayed diagnosis.

Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center

BACKGROUND

Child abuse is a serious threat to the physical and psychosocial well-being of the pediatric population. Musculoskeletal injuries are common manifestations of child abuse. There have been multiple studies that have attempted to identify the factors associated with, and the specific injury patterns seen with musculoskeletal trauma from child abuse, yet there have been no large studies that have used prospectively collected data and controlled comparisons. The purpose of our study was to describe the patterns of orthopaedic injury for child abuse cases detected in the large urban area that our institution serves, and to compare the injury profiles of these victims of child abuse to that of general (accidental) trauma patients seen in the emergency room and/or hospitalized during the same time period.

METHODS

This study is a retrospective review of prospectively collected information from an urban level I pediatric trauma center. Five hundred cases of child abuse (age birth to 48 mo) were identified by membership in our institution's Suspected Child Abuse and Neglect database collected between 1998 and 2007. These cases were compared against 985 general trauma (accidental) control patients of the same age group from 2000 to 2003. Age, sex, and injury type were compared.

RESULTS

Victims of child abuse were on average younger than accidental trauma patients in the cohort of patients under 48 months of age. There was no difference in sex distribution between child abuse and accidental trauma patients. When the entire cohort of patients under 48 months were examined after adjusting for age and sex, the odds of rib (14.4 times), tibia/fibula (6.3 times), radius/ulna (5.8 times), and clavicle fractures (4.4 times) were significantly higher in child abuse versus accidental trauma patients. When regrouping the data based on age, in patients younger than 18 months of age, the odds of rib (23.7 times), tibia/fibula (12.8 times), humerus (2.3 times), and femur fractures (1.8 times) were found to be significantly higher in the child abuse group. Yet, in the more than 18 months age group, the risk of humerus (3.4 times) and femur fractures (3.3 times) was actually higher in the accidental trauma group than in the child abuse group.

CONCLUSIONS

Patients who present to an urban level I pediatric trauma center and are victims of abuse are generally younger, and have an equal propensity to be male or female. It is important for the clinician to recognize that the age of the patient (younger or older than 18 mo and/or walking age) is an important determinant in identifying injury patterns suspicious for abuse. Patients below the age of 18 months who present with rib, tibia/fibula, humerus, or femur fractures are more likely to be victims of abuse than accidental trauma patients. Yet, when patients advance in age beyond 18 months, their presentation with long bone fractures (ie, femur and humerus) is more likely to be related to accidental trauma than child abuse.

LEVEL OF EVIDENCE

level III, prognostic study.

Análise de fraturas diafisárias do fêmur em crianças menores de 3 anos de idade

Este estudo consiste na reavaliação ortopédica e psicossocial de crianças que sofreram fratura do fêmur até a idade dos três anos e objetiva a análise de suas causas prováveis e detecção de indícios de ocorrência de Síndrome de Maus Tratos. Trinta e cinco crianças menores de três anos de idade sofreram fratura diafisária de fêmur e foram atendidas no Pronto Socorro do Serviço de Ortopedia e Traumatologia da Santa Casa de São Paulo, no período de janeiro de 1996 a agosto de 2002, sendo que 18 compareceram para reavaliação. Como causa relatada das fraturas observamos: queda em 13 (72,2%) casos, queda de objetos sobre o membro em três (16,7%) e fratura no parto em dois (11,1%). Constatamos suspeita de Síndrome dos Maus Tratos em nove (maus tratos físicos em seis [33,3%] e negligência em três [16,7%]) casos, fratura patológica em quatro (22,2%), causa acidental em três (16,7%), e outras causas em dois (11,1%) casos. Maus tratos constituem uma importante causa a ser investigada nos casos de fratura do fêmur em crianças com menos de três anos de idade, sendo o provável mecanismo responsável por metade das fraturas aqui estudadas.

Emergency department evaluation of child abuse

Child abuse has been documented in various forms since the beginning of recorded history. This article reviews the legal aspects of reporting child abuse, the epidemiology of child abuse, various physical manifestations of child abuse, and effective treatment procedures. It is only with the appropriate interventions that physicians can begin to make an impact on the future of abused children.