Prevalence of abuse among young children with femur fractures: a systematic review

Abstract

Background: Clinical factors that affect the likelihood of abuse in children with femur fractures have not been well elucidated. Consequently, specifying which children with femur fractures warrant an abuse evaluation is difficult. Therefore the purpose of this study is to estimate the proportion of femur fractures in young children attributable to abuse and to identify demographic, injury and presentation characteristics that affect the probability that femur fractures are secondary to abuse.

Methods: We conducted a systematic review of published articles written in English between January 1990 and July 2013 on femur fracture etiology in children less than or equal to 5 years old based on searches in PubMed/MEDLINE and CINAHL databases. Data extraction was based on pre-defined data elements and included study quality indicators. A meta-analysis was not performed due to study population heterogeneity.

Results: Across the 24 studies reviewed, there were a total of 10,717 children less than or equal to 60 months old with femur fractures. Among children less than 12 months old with all types of femur fractures, investigators found abuse rates ranging from 16.7% to 35.2%. Among children 12 months old or greater with femur fractures, abuse rates were lower: from 1.5% - 6.0%. In multiple studies, age less than 12 months, non-ambulatory status, a suspicious history, and the presence of additional injuries were associated with findings of abuse. Diaphyseal fractures were associated with a lower abuse incidence in multiple studies. Fracture side and spiral fracture type, however, were not associated with abuse.

Conclusions: Studies commonly find a high proportion of abuse among children less than 12 months old with femur fractures. The reported trauma history, physical examination findings and radiologic results must be examined for characteristics that increase or decrease the likelihood of abuse determination.

Figure 1

Processes of study identification, screening, eligibility assessment and inclusion.

Figure 2

Probability of Abuse in Children with a Femur Fracture, All Types. Proportion of cases with abusive femur fractures in included studies, by subject age criteria of inclusion. ^aUpper age limit was 11 months in Leventhal [10] & Wood [6] and 12 months in Hui [30]. ^bData for only the subset of children admitted to children’s hospitals or to general hospitals without children’s hospitals could be extracted. ^cStudy was limited to children with isolated femur fracture and no additional injuries. ^dIncluded children with reported history of stair fall ≤36 months old only. ^ePresents overall study methodology ranking (L1-L5) and abuse determination methodology ranking (1–5).

Figure 3

Probability of Abuse in Children with Diaphyseal Femur Fractures. ^aStudy was limited to children with isolated femur fractures without additional injuries. ^bPresents overall study methodology ranking (L1-L5) and abuse determination methodology ranking (1–5).