Multicentre study of physical abuse and limb fractures in young children in the East Anglia Region, UK

Abstract

ObjectiveTo determine if the detection of physical abuse in young children with fractures is of uniform high standard in the East Anglia Region of the UK, and whether we can identify areas for improvement in our detection of high-risk groups.DesignMulticentre retrospective 4-year study.Setting7 hospitals across the East Anglia Region of Britain (East Anglia Paediatric Physical Abuse and Fractures study).ParticipantsAge groups and fractures indicated as being at higher risk for physical abuse (all children under 12 months of age, and fractures of humerus and femur in children under 36 months of age).Outcome measuresOur criterion for physical abuse was the decision of a multiagency child protection case conference (CPCC).ResultsProbability of CPCC decision of physical abuse was highest in infants, ranging from 50% of fractures sustained in the first month of life (excluding obstetric injuries) to 10% at 12 months of age. Only 46%–86% of infants (under 12 months) with a fracture were assessed by a paediatrician for physical abuse after their fracture. Significant variation in the use of skeletal surveys and in CPCC decision of physical abuse was noted in children attending different hospitals.ConclusionsIt is a concern that significant variation between hospitals was found in the investigation and detection of physical abuse as confirmed by CPCC decisions. To minimise failure to detect true cases of physical abuse, we recommend that all high-risk children should be assessed by a paediatrician prior to discharge from the emergency department. Our proposed criteria for assessment (where we found probability of CPCC decision of physical abuse was at least 10%) are any child under the age of 12 months with any fracture, under 18 months of age with femur fracture and under 24 months with humeral shaft fracture (not supracondylar).

The Epidemiology of Infant Shaft Fractures of Femur or Humerus by Incidence, Birth, Accidents, and Other Causes

“…Shaft fractures of the humerus are also common in connection with abuse [24]. Our outcome of 10% of shaft humerus fractures having been assessed as abuse is lower than in a U.S. hospital study and a UK multicenter hospital study, which both reported that one third of humerus shaft fracture in children under the age of one year were associated with probable or indeterminate abuse [11,12]. Whether this discrepancy is due to different criteria for determination of abuse or a true difference cannot be ascertained.…”

“…Our proportion of femur shaft fractures attributed to abuse, 9%, is higher than in the Swedish nationwide study, which reported a gure of 4.2% [4] probably because we included those having an entry in the RCWM. These numbers can be compared with those in previous studies reporting that 21-31% of femur fractures (including fractures of the entire femur) in children under the age of 1 year were caused by child abuse [12,23]. Shaft fractures of the humerus are also common in connection with abuse [24].…”

“…Ethics approval and consent to participate The study was approved by the Regional Ethical Committee in Uppsala, Sweden (2014- [11][12][13][14][15][16][17][18][19]No. 383).…”

Challenges in comparing physical abuse, fractures and metabolic bone disease in young children in the UK and Sweden

“…We were very interested to hear of the views of Högberg et al regarding our paper recently published in ADC 1. We note that they are not criticising our study, but compare data from our paper with theirs on metabolic bone disease (MBD) in infants that was published in PLOS ONE in 2018 2.…”

Why is there a multi-fold difference in diagnosis of abuse among infants with long bone fracture in East Anglia compared with Sweden?

“…The multicentre hospital study by Mitchell et al 1 provides interesting regional representative data on limb fractures and diagnosis of physical abuse among young children. Their study enables intercountry considerations of fractures and physical abuse.…”