Long bone fractures in children under 3 years of age: is abuse being missed in Emergency Department presentations?

Abstract

Objective: Distinguishing injuries due to accidents from those due to child abuse in young children is important to prevent further abuse. We aimed to study the presenting features, mechanism of injury, type of fracture and indicators of possible abuse in children under 3 years of age, presenting to the Emergency Department (ED) of a tertiary referral Children's Hospital, to see whether those injuries that were more likely abusive were distinguished from those that were more likely accidental.

Methods: We analysed the medical records from the Emergency Department Information System of all children below 3 years of age, who were treated for a long bone fracture at the Sydney Children's Hospital, Randwick, NSW, over a 1-year period. Demographic details, presenting complaint, mechanism of injury, type of fracture, other historical and examination data and action taken were noted. Nine indicators that raise suspicion of abuse were developed from the literature. Using these indicators, patients' ED notes were reviewed to establish whether long bone fractures suspicious for abuse had been referred for further evaluation.

Results: One hundred patients with a total of 103 fractures presented during the study period. No child had multiple fractures at a single visit. The fractures included 36 radius/ulna, 27 tibia/fibula, 20 humeral, 17 clavicular and three femoral. The mean age of patients was 21.6 months (range 13 days - 35 months). Fourteen patients were younger than 12 months. Review of the notes revealed 31 children with indicators suspicious for abuse, of whom 17 children had one indicator, 11 children had two indicators, and three children had three indicators. Only one child was referred for further evaluation to child protection.

Conclusion: Abuse cannot usually be determined by fracture type alone. Doctors in the ED miss indicators for abuse because they do not look for these indicators in the history and examination. Knowledge of indicators that raise suspicion of abuse is needed for a further forensic assessment to occur. The development of specific referral guidelines, ongoing education and a comprehensive injury form may improve referral of children from the ED to child protection.