AEM Early Access 46: Identifying Maltreatment in Infants and Young Children Presenting With Fractures: Does Age Matter?

Welcome to the forty-sixth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to a recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

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DISCUSSING (OPEN ACCESS THROUGH January 31, 2021; CLICK ON TITLE TO ACCESS)

Identifying Maltreatment in Infants and Young Children Presenting With Fractures: Does Age Matter? Ian C. Mitchell MD, Bradley J. Norat MD, Marc Auerbach MD, MSCI, Colleen J. Bressler MD, John J Como MD, MPH, Mauricio A. Escobar Jr. MD, Katherine T. Flynn‐O’Brien MD, MPH, Daniel M. Lindberg MD, Todd Nickoles RN, MBA, Norell Rosado MD, Kerri Weeks MD, Sabine Maguire MBE, MBBCh.

Note: The authors would like to thank The John L Santikos and San Antonio Area Foundations for their gift to the Children’s Hospital of San Antonio Foundation in support of this work.

LISTEN NOW: INTERVIEW WITH authors

Ian C. Mitchell, MD

Clinical Associate Professor of Surgery, Baylor College of Medicine

Adjunct Associate Professor of Surgery, University of Texas Health Science Center at San Antonio

Sabine Maguire MBE, MBBCh

Paediatrician, Honorary Research Fellow

Cardiff University, Wales, UK

Bradley J. Norat MD, FAAP

Medical Director, Child Protection Team

Children’s Hospital of Michigan, Detroit, MI

ABSTRACT:

Objectives

Child abuse is a significant cause of morbidity and mortality in preverbal children who cannot explain their injuries. Fractures are among the most common injuries associated with abuse but of themselves fractures may not be recognized as abusive until a comprehensive child abuse evaluation is completed, often prompted by other signs or subjective features. We sought to determine which children presenting with rib or long‐bone fractures should undergo a routine abuse evaluation based on age.

Methods

A systematic review searching Ovid, PubMed/Medline, Scopus, and CINAHL from 1980 to 2020 was performed. An evidence‐based framework was generated by a consensus panel and applied to the results of the systematic review to form recommendations. Fifteen articles were suitable for final analysis.

Results

Studies with comparable age ranges of subjects and sufficient evidence to meet the determination of abuse standard for pediatric patients with rib, humeral, and femoral fractures were identified. Seventy‐seven percent of children presenting with rib fractures aged less than 3 years were abused; when those involved in motor vehicle collisions were excluded, 96% were abused. Abuse was identified in 48% of children less than 18 months with humeral fractures. Among those with femoral fractures, abuse was diagnosed in 34% and 25% of children aged less than 12 and 18 months, respectively.

Conclusion

Among children who were not in an independently verified incident, the authors strongly recommend routine evaluation for child abuse, including specialty child abuse consultation, for: 1) children aged less than 3 years old presenting with rib fractures and 2) children aged less than 18 months presenting with humeral or femoral fractures (Level of Evidence: III Review).