Identifying Maltreatment in Infants and Young Children Presenting With Fractures: Does Age Matter?

Abstract

Objectives Child abuse is a significant cause of morbidity and mortality in preverbal children who cannot explain their injuries. Fractures are among the most common injuries associated with abuse but of themselves fractures may not be recognized as abusive until a comprehensive child abuse evaluation is completed, often prompted by other signs or subjective features. We sought to determine which children presenting with rib or long‐bone fractures should undergo a routine abuse evaluation based on age. Methods A systematic review searching Ovid, PubMed/Medline, Scopus, and CINAHL from 1980 to 2020 was performed. An evidence‐based framework was generated by a consensus panel and applied to the results of the systematic review to form recommendations. Fifteen articles were suitable for final analysis. Results Studies with comparable age ranges of subjects and sufficient evidence to meet the determination of abuse standard for pediatric patients with rib, humeral, and femoral fractures were identified. Seventy‐seven percent of children presenting with rib fractures aged less than 3 years were abused; when those involved in motor vehicle collisions were excluded, 96% were abused. Abuse was identified in 48% of children less than 18 months with humeral fractures. Among those with femoral fractures, abuse was diagnosed in 34% and 25% of children aged less than 12 and 18 months, respectively. Conclusion Among children who were not in an independently verified incident, the authors strongly recommend routine evaluation for child abuse, including specialty child abuse consultation, for: 1) children aged less than 3 years old presenting with rib fractures and 2) children aged less than 18 months presenting with humeral or femoral fractures (Level of Evidence: III Review).

Defining suspected child maltreatment using International Classification of Diseases codes: A scoping literature review

“…In fact, the same code set was applied by another study of children under 18 years old without justification (Schilling, 2020). Likewise, rib fracture was identified as suggestive of physical abuse for children under two (Högberg, 2018; Lindberg, 2015), five (Schnitzer et al, 2011), and 18 (Matone, 2018; Schilling, 2020), while a meta-analysis on fracture in young children and infants and child maltreatment found that children under the age of three presenting with a rib fracture should raise the awareness for a child abuse evaluation (Mitchell et al, 2021). Because relevant codes for suspected maltreatment vary with age, future research proposing coding schemes should explicitly discuss upper and lower age limits for each diagnosis code.…”

Non-accidental Trauma in Infants: a Review of Evidence-Based Strategies for Diagnosis, Management, and Prevention

“…However, certain fracture patterns (CML, posterior rib fractures, scapular fractures, spinous process fractures, sternal fractures) have a much higher specificity for abuse than other fracture patterns (e.g., clavicular fractures, long bone shaft fractures) [77]. When excluding motor vehicle collisions, rib fractures were associated with abuse in 96% of cases in children < 3 years of age [78]. Furthermore, age < 12 months, rather than anatomic location, was the only risk factor associated with increased incidence of abuse in the setting of rib fractures [79].…”

“…Furthermore, age < 12 months, rather than anatomic location, was the only risk factor associated with increased incidence of abuse in the setting of rib fractures [79]. Similarly, long bone fractures of the humerus or femur have a high incidence (25-48%) in abused children and especially infants [73,78,80]. Skull fractures, on the other hand, are the most common presenting fracture and are associated with abuse in < 20% of cases, especially when simple and linear [73].…”

Child physical abuse trauma evaluation and management: A Western Trauma Association and Pediatric Trauma Society critical decisions algorithm

“…25,26 The correlation of CPA and isolated humerus or femur fracture in a child younger than 18 months was a finding by members of the PTS guidelines committee. 27…”