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Features differentiating fractures due to abuse.


When infants and toddlers present with a fracture in the absence of a confirmed cause, physical abuse should be considered as a potential cause, according to researchers.

Children who have been physically abused represent a small proportion of the total number of childhood fractures--most are from falls, motor vehicle crashes or other non-abusive trauma. A small group are also susceptible to fractures owing to underlying conditions that contribute to bone fragility. All healthcare professionals who see children should be able to recognise the characteristics of fractures resulting from abuse and initiate child protection investigations where necessary, to prevent further injury that could be fatal. In reality, the possibility of child abuse is often overlooked in clinical practice.

To identify which features differentiate fractures resulting from abuse from those sustained from other causes, Cardiff University researchers systematically reviewed published world literature, including 32 studies. Fractures resulting from abuse were recorded throughout the skeletal system, most commonly in infants (less than one year) and toddlers (one to three years). Multiple fractures were more common in cases of abuse. Excluding major trauma, rib fractures had the highest probability for abuse. No one fracture in isolation was specific for abuse, but it should be considered in the differential diagnosis when an infant under 18 months presents with a fracture in the absence of an overt history of important trauma or a known medical condition that predisposes to bone fragility. Indicators that can inform decisions about the likelihood of abuse include:

* Rib fractures, regardless of type, are highly specific for abuse in the absence of an overt traumatic or organic cause

* Fractures from abuse are significantly more common in children under 18 months than in older children

* Multiple fractures are more common after physical abuse than after non-abusive traumatic injury

* A child with a femoral fractures has a one-in-three to-four chance of having been abused

* Femoral fractures resulting from abuse are more commonly seen in children who are not yet walking

* A child aged under three with a humeral fracture has a one-in-two chance of having been abused

* An infant or toddler with skull fractures has a one-in-three chance of having been abused. Kemp Am Dunstan F, Harrison S, Morris m Mann M, Rolfe, S, Thomas P, Sibert J, Maguire S. Patterns of skeletal fractures in child abuse: systematic review. British Medical Journal, 2008; doi: 10.1136/bmj.a1518 (2 October 2008).
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Title Annotation:CLINICAL PAPERS
Author:Thompson, June
Publication:Community Practitioner
Geographic Code:4EUUK
Date:Dec 1, 2008
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