Identifying Child Abuse in Patients With Femur Fractures Through Pathway Compliance: A Pilot Study

Abstract

Background Child abuse is a significant cause of morbidity and mortality in children. A thorough history and physical exam is critical to identifying abuse. Standardized screening tools as well as clinical pathways can assist with identifying patients who may have an injury secondary to abuse. There are varied recommendations for the upper age in which to routinely evaluate pediatric patients for child abuse. Objectives The primary objective of this study was to describe the outcomes of the implementation of an evidence-based clinical pathway for suspected non-accidental trauma for all pediatric patients aged five years and under presenting with a femur fracture. This pathway includes orders for imaging, labs, and consults. In addition, the characteristics of this population and the findings were described. Methods A retrospective study of patients at a single institution who met the National Trauma Data Standard registry inclusion criteria and had a femur fracture was performed. Variables analyzed included age, demographics, mechanism and location of injury, admission status and service, injury severity, hospital characteristics, and discharge status. Patients with a metabolic bone disease were excluded. Results There were 200 patients who met the inclusion criteria. Thirty-two patients had a diagnosis of confirmed or suspected child abuse. While all 32 patients had a skeletal survey performed, only 23 (71.9%) had the complete workup per the clinical pathway, and 21 (65.6%) had a diagnosis of confirmed child abuse. Conclusion Clinical pathways are established to provide the standardization of clinical assessments and interventions; however, this process relies on a single individual to make a judgment determining whether or not to implement the pathway. Children presenting to an emergency department with confirmed or suspected child abuse are a vulnerable population. A child abuse diagnosis is a clinical judgment; however, clinical pathways aid in the diagnosis in hopes to stop any further abuse. For a pathway to be successful, each step needs to be addressed.