Paediatric femur fractures at the emergency department: accidental or not?

Abstract

Only a small proportion of all paediatric fractures is caused by child abuse or neglect, especially in highly prevalent long bone fractures. It can be difficult to differentiate abusive fractures from non-abusive fractures. This article focuses on femoral fractures in young children. Based on three cases, this article presents a forensic evidence-based approach to differentiate between accidental and non-accidental causes of femoral fractures. We describe three cases of young children who were presented to the emergency department because of a suspected femur fracture. Although in all cases, the fracture had a similar location and appearance, the clinical history and developmental stage of the child led to three different conclusions. In the first two cases, an accidental mechanism was a plausible conclusion, although in the second case, neglect of parental supervision was the cause for concern. In the third case, a non-accidental injury was diagnosed and appropriate legal prosecution followed. Any doctor treating children should always be aware of the possibility of child abuse and neglect in children with injuries, especially in young and non-mobile children presenting with an unknown trauma mechanism. If a suspicion of child abuse or neglect arises, a thorough diagnostic work-up should be performed, including a full skeletal survey according to the guidelines of the Royal College of Radiologists and the Royal College of Paediatrics and Child Health. In order to make a good assessment, the radiologist reviewing the skeletal survey needs access to all relevant clinical and social information.

Prevalence of inflicted and neglectful femur shaft fractures in young children in national level I trauma centers

“…As a consequence, infant bones do not need much force to be fractured and femur fractures in children can be caused by low-velocity incidents or by an indirect impact [ 31 ]. Spiral fractures are not specific for inflicted trauma/neglect; their presence merely implies that fracture was caused by a torsional force and may be a result of minimal force [ 1 , 32 ]. Pierce et al [ 33 ] used a biomechanical model on femur fractures in children who fell down the stairs and showed that transverse and short oblique fractures were associated with almost tenfold higher injury biomechanical measures compared to spiral and bucket handle fractures.…”

Notificações de maus-tratos em um hospital infantil: Avaliação do perfil epidemiológico e sua relação com o desfecho em fraturas

“…Table 3 Typology of cases of maltreatment, its consequences, and outcome "bone fractures" according to the sex of the victims (according to the type of violence, the environment, the presence of fractures, the type of fracture, whether there was consultation with an orthopedist and whether there was a need for surgery or deaths), SINAN Corroborating national and international research, 2-6,12 neglect (53.9%) and physical aggression (39.1%) were the most prevalent typologies, with similar distribution between genders. The high prevalence of the latter may be related to the use of physical force as a form of "education" or disciplinary practice, 1,2,12 where parents who were raised through punishment and physical punishment perpetrate this culturally accepted habit, 1,2 regardless of the existence of public policies, such as Law No. 13,010-"Lei do Menino Bernardo" (Bernardo Boy Law) 27 or the Statute of the Child and Adolescent.…”

“…A suspeita deve ser aventada com cautela quando as lesões não correspondem ao mecanismo de trauma ou à história declarada. 2,3,6,7,12,13 Danos térmicos, lesões inexplicáveis de tecidos moles ou no crânio, fraturas nas costelas e/ou múltiplas, atraso na busca de atendimento médico ou qualquer lesão em uma criança que ainda não anda, devem chamar a atenção do profissional de saúde. [2][3][4]7 Lesões na coluna são raras em crianças, mas que podem acontecer em vítimas de violência.…”

“…Suspicion should be advanced with caution when the lesions do not correspond to the mechanism of trauma or the declared history. 2,3,6,7,12,13 Thermal damage, unexplained soft tissue or skull injuries, rib and/or multiple fractures, delay in seeking medical attention, or any injury to a child who is not yet walking should draw the attention of the healthcare professional. [2][3][4]7 Spinal injuries are rare in children, but they can happen in victims of violence.…”

“…6,7 Orthogonal radiographs of the skull, spine, long bones, hands, and feet are relevant in cases of suspected violence. 3,6,7,12,[16][17][18] However, they do not replace the anamnesis since it is necessary to confirm the compatibility of the report of the trauma mechanism with that evidenced in the image. 2,3,6,7,13,14 Age is one of the most important characteristics in distinguishing between accidental trauma and violence.…”