Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures. Pediatrics 2014;133:e477-e489 INTRODUCTIONFractures are the second most common injury caused by child physical abuse; bruises are the most common injury. 1 Failure to identify an injury caused by child abuse and to intervene appropriately may place a child at risk for further abuse, with potentially permanent consequences for the child. 2-4 Physical abuse may not be considered in the physician' s differential diagnosis of childhood injury because the caregiver may have intentionally altered the history to conceal the abuse. 5 As a result, when fractures are initially evaluated, a diagnosis of child abuse may be missed. 3 In children younger than 3 years, as many as 20% of fractures caused by abuse may be misdiagnosed initially as noninflicted or as attributable to other causes. 3 In addition, fractures may be missed because radiography is performed before changes are obvious or the radiographic images are misread or misinterpreted. 2 However, incorrectly diagnosing physical abuse in a child with noninflicted fractures has serious consequences for the child and family. To identify child abuse as the cause of fractures, the physician must take into consideration the history, the age of the child, the location and type of fracture, the mechanism that causes the particular type of fracture, and the presence of other injuries while also considering other possible causes. DIFFERENTIAL DIAGNOSIS OF FRACTURES Trauma: Child Abuse Versus Noninflicted InjuriesFractures are a common childhood injury and account for between 8% and 12% of all pediatric injuries. [6][7][8] In infants and toddlers, physical FROM THE AMERICAN ACADEMY OF PEDIATRICSGuidance for the Clinician in Rendering Pediatric Care by guest on May 11, 2018 http://pediatrics.aappublications.org/ Downloaded from abuse is the cause of 12% to 20% of fractures. 9 Although unintentional fractures are much more common than fractures caused by child abuse, the physician needs to remain aware of the possibility of inflicted injury. Although some fracture types are highly suggestive of physical abuse, no pattern can exclude child abuse. 10,11 Specifically, it is important to recognize that any fracture, even fractures that are commonly noninflicted injuries, can be caused by child abuse. Certain details that can help the physician determine whether a fracture was caused by abuse rather than unintentional injury include the hist...

The number of anterior cruciate ligament (ACL) injuries reported in athletes younger than 18 years has increased over the past 2 decades. Reasons for the increasing ACL injury rate include the growing number of children and adolescents participating in organized sports, intensive sports training at an earlier age, and greater rate of diagnosis because of increased awareness and greater use of advanced medical imaging. ACL injury rates are low in young children and increase sharply during puberty, especially for girls, who have higher rates of noncontact ACL injuries than boys do in similar sports. Intrinsic risk factors for ACL injury include higher BMI, subtalar joint overpronation, generalized ligamentous laxity, and decreased neuromuscular control of knee motion. ACL injuries often require surgery and/or many months of rehabilitation and substantial time lost from school and sports participation. Unfortunately, regardless of treatment, athletes with ACL injuries are up to 10 times more likely to develop degenerative arthritis of the knee. Safe and effective surgical techniques for children and adolescents continue to evolve. Neuromuscular training can reduce risk of ACL injury in adolescent girls. This report outlines the current state of knowledge on epidemiology, diagnosis, treatment, and prevention of ACL injuries in children and adolescents.

Objective-To analyse all clinical presentations to the crowd doctors at Scotland's largest football stadium over the course of one complete season. Methods-A standard clinical record form was used to document all consultations with the crowd doctors including treatment and subsequent referrals. The relevance of alcohol consumption was assessed. Results-A total of 127 casualties were seen at 26 matches, a mean of 4.88 per match. Twenty casualties were transferred to hospital, including one successfully defibrillated after a cardiac arrest. Alcohol excess was a major contributing factor in 26 cases. Conclusions-The workload of the crowd doctors was very variable and diverse. The social problem of excessive alcohol consumption contributed considerably to the workload. The provision of medical facilities at football grounds means that attendance there is now one of the least adverse circumstances in which to have a cardiac arrest. The study confirmed previous impressions that more casualties are seen at high profile matches. (Br J Sports Med 2001;35:245-250)

Background: The majority of previous investigations on operative fixation of clavicle fractures have been related to the adult population, with occasional assessments of the younger, more commonly affected adolescent population. Despite limited prospective data for adolescents, the incidence of operative fixation of adolescent diaphyseal clavicle fractures has increased. Purpose: To detail the demographic features and descriptive epidemiology of a large pooled cohort of adolescent patients with diaphyseal clavicle fractures presenting to pediatric tertiary care centers in the United States through an observational, prospective, multicenter cohort study (Function after Adolescent Clavicle Trauma and Surgery [FACTS]). Study Design: Cross-sectional study; Level of evidence, 4. Methods: Patients aged 10 to 18 years who were treated for a diaphyseal clavicle fracture between August 2013 and February 2016 at 1 of 8 geographically diverse, high-volume, tertiary care pediatric centers were screened. Treatment was rendered by any of the pediatric orthopaedic providers at each of the 8 institutions, which totaled more than 50 different providers. Age, sex, race, ethnicity, fracture laterality, hand dominance, mechanism of injury, injury activity, athletic participation, fracture characteristics, and treatment decisions were prospectively recorded in those who were eligible and consented to enroll. Results: A total of 545 patients were included in the cohort. The mean age of the study population was 14.1 ± 2.1 years, and 79% were male. Fractures occurred on the nondominant side (56%) more frequently than the dominant side (44%). Sport was the predominant activity during which the injury occurred (66%), followed by horseplay (12%) and biking (6%). The primary mechanism of injury was a direct blow/hit to the shoulder (60%). Overall, 54% were completely displaced fractures, defined as fractures with no anatomic cortical contact between fragments. Mean shortening within the completely displaced group was 21.9 mm when measuring the distance between fragment ends (end to end) and 12.4 mm when measuring the distance between the fragment end to the corresponding cortical defect (cortex to corresponding cortex) on the other fragment (ie, true shortening). Comminution was present in 18% of all fractures. While 83% of all clavicle fractures were treated nonoperatively, 32% of completely displaced fractures underwent open reduction and internal fixation. Conclusion: Adolescent clavicle fractures occurred more commonly in male patients during sports, secondary to a direct blow to the shoulder, and on the nondominant side. Slightly more than half of these fractures were completely displaced, and approximately one-fifth were comminuted. Within this large cohort, approximately one-third of patients with completely displaced fractures underwent surgery, allowing for future prospective comparative analyses of radiographic, clinical, and functional outcomes.