Evaluation for Occult Fractures in Injured Children

Abstract

OBJECTIVES: To examine variation across US hospitals in evaluation for occult fractures in (1) children ,2 years old diagnosed with physical abuse and (2) infants ,1 year old with injuries associated with a high likelihood of abuse and to identify factors associated with such variation. METHODS:We performed a retrospective study in children ,2 years old with a diagnosis of physical abuse and in infants ,1 year old with non-motor vehicle crash-related traumatic brain injury or femur fractures discharged from 366 hospitals in the Premier database from 2009 to 2013. We examined across-hospital variation and identified child-and hospital-level factors associated with evaluation for occult fractures.RESULTS: Evaluations for occult fractures were performed in 48% of the 2502 children with an abuse diagnosis, in 51% of the 1574 infants with traumatic brain injury, and in 53% of the 859 infants with femur fractures. Hospitals varied substantially with regard to their rates of evaluation for occult fractures in all 3 groups. Occult fracture evaluations were more likely to be performed at teaching hospitals than at nonteaching hospitals (all P , .001). The hospital-level annual volume of young, injured children was associated with the probability of occult fracture evaluation, such that hospitals treating more young, injured patients were more likely to evaluate for occult fractures (all P , .001).CONCLUSIONS: Substantial variation in evaluation for occult fractures among young children with a diagnosis of abuse or injuries associated with a high likelihood of abuse highlights opportunities for quality improvement in this vulnerable population.WHAT'S KNOWN ON THIS SUBJECT: Screening for occult fractures is a key component of the medical evaluation for young victims of suspected physical abuse. Little is known about adherence to occult fracture evaluation guidelines in children with suspected abuse cared for at non-pediatric-focused hospitals.WHAT THIS STUDY ADDS: Occult fracture evaluations were performed in half of young children diagnosed with abuse or injuries concerning for abuse in a large cohort of hospitals. Evaluations were more common at hospitals caring for higher volumes of young, injured children.

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

“…32 Despite the fact that guidelines are readily available, a recent study in a large number of hospitals in the USA showed that there was substantial variation in the proportion of children receiving the appropriate radiological work-up after a diagnosis or high likelihood of abuse. 34 Overall, only half of all children underwent a skeletal survey, and teaching hospitals and hospitals with a high caseload of injured children performed more skeletal surveys. 34 Other studies in the USA, UK and Netherlands showed similar results.…”

“…34 Overall, only half of all children underwent a skeletal survey, and teaching hospitals and hospitals with a high caseload of injured children performed more skeletal surveys. 34 Other studies in the USA, UK and Netherlands showed similar results. 31,[35][36][37] For the reporting radiologist, it is important that, just like in all other cases, the radiology request clearly states the indication for the skeletal survey, including details on current clinical problems, mode of presentation and relevant (medical-, family-and social) history.…”

Development of Guidelines for Skeletal Survey in Young Children With Intracranial Hemorrhage

“…9 Even greater variation in rates of occult fracture evaluation in this population were observed in a study of primarily non-pediatric hospitals; rates of SS performance ranged from 26% to 98% after adjusting for case mix. 10 Previous studies have also shown that among infants with similar type and severity of traumatic brain injury, infants of minority race or without private insurance were more likely to undergo SS than infants of white race or with private insurance. 7,11 Utilization of more specific guidelines for performing SS may eliminate these disparities and variations in evaluation.…”

Research priorities for a multi-center child abuse pediatrics network − CAPNET

“…These findings suggest that implicit biases of medical providers may contribute to disproportionately high rates of child abuse evaluation and reporting for poor or African-American families, and disproportionately high rates of missed abuse in affluent, or White families. (Jenny, Hymel, Ritzen, Reinert, & Hay, 1999; Lindberg et al, 2015; Wood et al, 2012a; Wood, French, Song, & Feudtner, 2015; Wood et al, 2010)…”

“…(Bradford, Choudhary, & Dias, 2013; Christian & Block, 2009; Postema, Sieswerda-Hoogendoorn, Majoie, & van Rijn, 2014; Sieswerda-Hoogendoorn, Postema, Verbaan, Majoie, & van Rijn, 2014) Further, variable practice patterns and systems of care for medical, social and law-enforcement professionals limit the generalizability of single center results. (Hooft et al, 2015; Lindberg et al, 2015; Lindberg, Lindsell, & Shapiro, 2008; Wood et al, 2012b; Wood, 2015; Wood, 2014)…”