Patterns of skeletal fractures in child abuse: systematic review

Abstract

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.

Evaluating Children With Fractures for Child Physical Abuse

“…15,49,50 In contrast, supracondylar fractures in ambulatory children are usually noninflicted injuries resulting from short falls. 15 Physicians should also be aware of a particular mechanism reported to produce a noninflicted spiral-oblique fracture of the humerus in 1 case report. 51 When the young infant was rolled from the prone position to the supine while the child' s arm is extended, the torsion and stress placed on the extended arm appeared to cause a spiral-oblique fracture of the midshaft of the humerus.…”

“…Rib fractures have high probability of being caused by abuse. 15,17,21 The positive predictive value of rib fractures for child abuse in children younger than 3 years was 95% in one retrospective study. 22 Other less common causes of rib fractures in infants include significant trauma sustained during childbirth or a motor vehicle crash as well as minor trauma in infants who have increased bone fragility.…”

“…43 A fracture of the humeral shaft in a child younger than 18 months has a high likelihood of having been caused by abuse. 15,49,50 In contrast, supracondylar fractures in ambulatory children are usually noninflicted injuries resulting from short falls. 15 Physicians should also be aware of a particular mechanism reported to produce a noninflicted spiral-oblique fracture of the humerus in 1 case report.…”

“…Approximately 80% of all fractures caused by child abuse occur in children younger than 18 months, 12 and approximately one-quarter of fractures in children younger than 1 year are caused by child abuse. 1,9,[13][14][15] Physical abuse is more likely to be the cause of femoral fractures and humeral fractures in children who are not yet walking compared with children who are ambulatory, [15][16][17][18] and the percentage of fractures caused by abuse declines sharply after the child begins to walk. 9,19,20 Fracture Specificity for Abuse…”

Skull and Posterior Rib Fractures with Respiratory Failure caused by Child Abuse

“…1 They occur in infants and toddlers (under three years old) who cannot give a causal explanation about the fracture, and the incidence is around 78%. Worlock and colleagues studied children under 12 years old and showed that 80% of all fractures from abuse are seen in children under 18 months, contrary, 85% of fractures not caused by abuse occurred in children over 5 years.…”