Understanding humerus fractures in young children: Abuse or not abuse?

Abstract

Fractures are the second most common abusive injury occurring in young children, particularly those under 2 years of age. The humerus is often affected. To better identify factors discriminating between abusive and non-abusive humerus fractures, this retrospective study examined the characteristics and mechanisms of injuries causing humerus fractures in children less than 18 months of age. Electronic medical records were reviewed for eligible patients evaluated between September 1, 2007 and January 1, 2012 at two children's hospitals in Chicago, IL. The main outcome measures were the type of fracture and the etiology of the fracture (abuse vs not abuse). The 97 eligible patients had 100 humerus fractures. The most common fracture location was the distal humerus (65%) and the most common fracture type was supracondylar (48%). Child Protection Teams evaluated 44 patients (45%) and determined that 24 of those had 25 fractures caused by abuse (25% of the total study population).Among children with fractures determined to have been caused by abuse, the most common location was the distal humerus (50%) and the most common types were transverse and oblique (25% each); however, transverse and oblique fractures were also seen in patients whose injuries were determined to have been non-abusive. A younger age, non-ambulatory developmental stage, and the presence of additional injuries were significantly associated with abusive fractures. Caregivers did not provide a mechanism of injury for half of children with abusive fractures, whereas caregivers provided some explanation for all children with non-abusive fractures.

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

“…Rosado et al 26 conducted a cross‐sectional study of the records of all children less than 18 months of age presenting with a humeral fracture. Of the 48 patients 12 months and younger, 22 were determined to have suffered an abusive fracture, while 10 were not abusive and five were indeterminate.…”

“…In summary, in this countywide study, 100% of humeral fractures in infants less than 18 months were due to abuse, while the incidence of abusive humeral fractures in children aged 19 months to 5 years was only 2%. Rosado et al 26 conducted a cross-sectional study of the records of all children less than 18 months of age presenting with a humeral fracture. Of the 48 patients 12 months and younger, 22 were determined to have suffered an abusive fracture, while 10 were not abusive and five were indeterminate.…”

Epidemiology of Displaced Supracondylar Fractures

“…The average age of supracondylar fractures is six years [3,6,7,13,16]. Supracondylar fractures begin to occur in children after the age of one, and peak at the age of six.…”

“…In our cohort, 73 of the 75 children with supracondylar fractures were older than two. Unless other evidence of abuse is present -such as multiple fractures, bruises, or an inconsistent history, a single fracture is unlikely the result of abuse in an ambulatory-age child [13][14][15][16]. In a non-ambulatory child less than two years of age with a supracondylar fracture, child abuse should be considered.…”

“…The results of the current study and literature review demonstrate that a supracondylar fracture by itself should not be a red flag for abuse. Some factors helpful for identifying pediatric abuse include a non-ambulatory infant, multiple fractures, corner fractures, additional skin bruising, an inconsistent history, and a delayed presentation [13][14][15][16]. The limitations of this study included use of a single surgeon's sample, the retrospective design, inclusion of only displaced fractures undergoing surgery, and small sample size.…”