Objectives To systematically review published studies to identify the characteristics that distinguish fractures in children resulting from abuse and those not resulting from abuse, and to calculate a probability of abuse for individual fracture types.Design Systematic review.Data sources All language literature search of Medline, Medline in Process, Embase, Assia, Caredata, Child Data, CINAHL, ISI Proceedings, Sciences Citation, Social Science Citation Index, SIGLE, Scopus, TRIP, and Social Care Online for original study articles, references, textbooks, and conference abstracts until May 2007.Study selection Comparative studies of fracture at different bony sites, sustained in physical abuse and from other causes in children <18 years old were included. Review articles, expert opinion, postmortem studies, and studies in adults were excluded.Data extraction and synthesis Each study had two independent reviews (three if disputed) by specialist reviewers including paediatricians, paediatric radiologists, orthopaedic surgeons, and named nurses in child protection. Each study was critically appraised by using data extraction sheets, critical appraisal forms, and evidence sheets based on NHS Centre for Reviews and Dissemination guidance. Meta-analysis was done where possible. A random effects model was fitted to account for the heterogeneity between studies.Results In total, 32 studies were included. Fractures resulting from abuse were recorded throughout the skeletal system, most commonly in infants (<1 year) and toddlers (between 1 and 3 years old). Multiple fractures were more common in cases of abuse. Once major trauma was excluded, rib fractures had the highest probability for abuse (0.71, 95% confidence interval 0.42 to 0.91). The probability of abuse given a humeral fracture lay between 0.48 (0.06 to 0.94) and 0.54 (0.20 to 0.88), depending on the definition of abuse used. Analysis of fracture type showed that supracondylar humeral fractures were less likely to be inflicted. For femoral fractures, the probability was between 0.28 (0.15 to 0.44) and 0.43 (0.32 to 0.54), depending on the definition of abuse used, and the developmental stage of the child was an important discriminator. The probability for skull fractures was 0.30 (0.19 to 0.46); the most common fractures in abuse and non-abuse were linear fractures. Insufficient comparative studies were available to allow calculation of a probability of abuse for other fracture types.Conclusion When infants and toddlers present with a fracture in the absence of a confirmed cause, physical abuse should be considered as a potential cause. No fracture, on its own, can distinguish an abusive from a non-abusive cause. During the assessment of individual fractures, the site, fracture type, and developmental stage of the child can help to determine the likelihood of abuse. The number of high quality comparative research studies in this field is limited, and further prospective epidemiology is indicated.

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This study shows that it is possible to visualize an epidural catheter in the epidural space in children under 6 months of age using ultrasound.

The results of this study show that fractures in young children may be dated as acute (< 1 week), recent (8-35 days), or old (≥ 36 days) on the basis of the presence of six key radiologic features in combination. Furthermore, good interobserver agreement suggests these results are reproducible.

Radiologic dating of fractures is an inexact science. Most radiologists date fractures on the basis of their personal clinical experience, and the literature provides little consistent data to act as a resource. There is an urgent need for research to validate the criteria used in the radiologic dating of fractures in children younger than 5 years.

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IntroductionNeonatal fractures raise concern about non-accidental injury (NAI). This case series explores the characteristics of fractures on a neonatal intensive care unit (NICU).MethodBabies admitted to a regional NICU from 1998–2007with a radiological fracture during their inpatient stay were identified. Possible aetiology for fractures was identified from in-patient records.ResultsFifty-one fractures were identified in 22 (14 male) infants, median (range) gestational age 28 (26–43) weeks and birthweight 1581 (485–4875) g. Fractures occurred at median age of 53 (0–106) days and the sites included 19 anterior or lateral rib, 14 posterior rib, 3 humeral, 2 ulnar, 3 radial, 6 femur, 1 tibial, 2 clavicular and 1 skull. 17 cases had explanations for their fracture including osteopaenia of prematurity, birth trauma, thoracotomy and a witnessed accidental fall. Rib fractures occurred significantly later than other fractures (75.5 vs 21 days, p=0.03) and posterior rib fractures were found in the more preterm babies (26 vs 29 weeks, p=0.04). Babies with rib fractures were more likely to have had a surgical procedure (p=0.01) but fewer had a history of birth trauma (p=0.02).ConclusionFractures sustained during an inpatient stay on a NICU are unlikely to be associated with NAI. However, this case series demonstrated that fractures occur for a variety of possible associated factors. Careful consideration to causation needs to be given to fractures in babies after discharge from a NICU. Although they could be caused by NAI, prematurity and/or low birthweight and previous treatment needs to be considered.