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Results

The following is a summary of the systematic review findings up to the date of our most recent literature search. If you have a specific clinical case, we strongly recommend you read all of the relevant references as cited and look for additional material published outside our search dates.

 

Overall results

  • Study designs:
    • 35 cross-sectional 2,6-8,10,12,13,15,18-20,23,24,29,32,35-37,47,50-54,56,68,72,73,75-78,80,84,85,87,88,90
    • 41 case study / case series 1,3,5,9,11,14,16,17,21,22 25-28,30,31,33,34,39-42,44-46,49,55,57-62,65-67,69-71,74,79,81-83,89 
    • 6 case-control 4,43,48,63,64,91
    • 1 cohort 38
    • 1 cross-sectional & sub-series 86
  • Age range: 0 – 17 years
  • No comparative study addressed disabled children
  • One non-comparative study showed that 33% of abused children with fractures aged 3-12 years, and 60% of abused adolescents with fractures had concomitant psychiatric or neurological conditions 53

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References

    1. Ablin DS, Greenspan A, Reinhart MA. Pelvic injuries in child abuse. Pediatric Radiology. 1992;22(6):454-457 [Pubmed]
    2. Anderson WA. The significance of femoral fractures in children. Annals of Emergency Medicine. 1982;11(4):174-177 [Pubmed]
    3. Arkader A, Friedman JE, Warner WC, Jr., Wells L. Complete distal femoral metaphyseal fractures: a harbinger of child abuse before walking age. Journal of Pediatric Orthopedics. 2007;27(7):751-753 [Pubmed]
    4. Baldwin K, Pandya NK, Wolfgruber H, Drummond DS, Hosalkar HS. Femur fractures in the pediatric population: abuse or accidental trauma? Clinical Orthopaedics and Related Research. 2011;469(3):798-804 [Pubmed]
    5. Barber I, Perez-Rossello JM, Wilson CR, Kleinman PK. The yield of high-detail radiographic skeletal surveys in suspected infant abuse. Pediatric Radiology. 2015;45(1):69-80 [Pubmed]

    6. Barsness KA, Cha ES, Bensard DD, Calkins CM, Partrick DA, Karrer FM, Strain JD. The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. Journal of Trauma - Injury Infection & Critical Care. 2003;54(6):1107-1110 [Pubmed]
    7. Beals RK, Tufts E. Fractured femur in infancy: the role of child abuse. Journal of Pediatric Orthopaedics. 1983;3(5):583-586 [Pubmed]
    8. Billmire ME, Myers PA. Serious head injuries in infants: accident or abuse? Pediatrics. 1985;75(2):340-342 [Pubmed]
    9. Bixby SD, Wilson CR, Barber I, Kleinman PK. Ischial apophyseal fracture in an abused infant. Pediatric Radiology. 2014;44(9):1175-1178 [Pubmed]

    10. Blakemore LC, Loder RT, Hensinger RN. Role of intentional abuse in children 1 to 5 years old with isolated femoral shaft fractures. Journal of Pediatric Orthopaedics. 1996;16(5):585-588 [Pubmed]
    11. Bode KS, Newton PO. Pediatric nonaccidental trauma thoracolumbar fracture-dislocation: posterior spinal fusion with pedicle screw fixation in an 8-month-old boy. Spine. 2007;32(14):E388-E393 [Pubmed]
    12. Bulloch B, Schubert CJ, Brophy PD, Johnson N, Reed MH, Shapiro RA. Cause and clinical characteristics of rib fractures in infants. Pediatrics. 2000;105(4):E48 [Pubmed]
    13. Cadzow SP, Armstrong KL. Rib fractures in infants: red alert! The clinical features, investigations and child protection outcomes. Journal of Paediatrics and Child Health. 2000;36(4):322-326 [Pubmed]
    14. Carrion WV, Dormans JP, Drummond DS, Christofersen MR. Circumferential growth plate fracture of the thoracolumbar spine from child abuse. Journal of Pediatric Orthopaedics. 1996;16(2):210-214 [Pubmed]
    15. Coffey C, Haley K, Hayes J, Groner JI. The risk of child abuse in infants and toddlers with lower extremity injuries. Journal of Pediatric Surgery. 2005;40(1):120-123 [Pubmed]
    16. Cosway B, Mathura N, Mott A, Bredow M, Fraser J, Rawlinson A, Wei C, Thyagarajan M, Harrison S, Kemp A. Occult rib fractures: Defining the cause. Child Abuse Review. 2013. [Early View - Abstract available from Wiley online library]

    17. Cullen JC. Spinal lesions in battered babies. The Journal of Bone and Joint Surgery. 1975;57(3):364-366 [Pubmed]
    18. Dalton HJ, Slovis T, Helfer RE, Comstock J, Scheurer S, Riolo S. Undiagnosed abuse in children younger than 3 years with femoral fracture. American Journal of Diseases of Children. 1990;144(8):875-878 [Pubmed]
    19. Darling SE, Done SL, Friedman SD, Feldman KW. Frequency of intrathoracic injuries in children younger than 3 years with rib fractures. Pediatric Radiology. 2014;44(10):1230-1236 [Pubmed]

    20. DeLee JC, Wilkins KE, Rogers LF, Rockwood CA. Fracture-separation of the distal humeral epiphysis. The Journal of Bone and Joint Surgery. 1980;62(1):46-51 [Pubmed]
    21. Diamond P, Hansen CM, Christofersen MR. Child abuse presenting as a thoracolumbar spinal fracture dislocation: a case report. Pediatric Emergency Care. 1994;10(2):83-86 [Pubmed]
    22. Dickson RA, Leatherman KD. Spinal injuries in child abuse: case report. The Journal of Trauma. 1978;18(12):811-812 [Pubmed]
    23. Ellerstein NS, Norris KJ. Value of radiologic skeletal survey in assessment of abused children. Pediatrics 1984;74(6):1075-1078 [Pubmed]
    24. Farnsworth CL, Silva PD, Mubarak SJ. Etiology of supracondylar humerus fractures. Journal of Pediatric Orthopaedics. 1998;18(1):38-42 [Pubmed]
    25. Feldman KW, Avellino AM, Sugar NF, Ellenbogen RG. Cervical spinal cord injury in abused children. Pediatric Emergency Care. 2008;24(4):222-227 [Pubmed]
    26. Feldman KW, Brewer DK. Child abuse, cardiopulmonary resuscitation, and rib fractures. Pediatrics. 1984;73(3):339-342 [Pubmed]
    27. Forlin E, Guille JT, Kumar SJ, Rhee KJ. Transepiphyseal fractures of the neck of the femur in very young children. Journal of Pediatric Orthopaedics. 1992;12(2):164-168 [Pubmed]
    28. Gabos PG, Tuten HR, Leet A, Stanton RP. Fracture-dislocation of the lumbar spine in an abused child. Pediatrics. 1998;101(3 Pt 1):473-477 [Pubmed citation only]
    29. Garcia VF, Gotschall CS, Eichelberger MR, Bowman LM. Rib fractures in children: a marker of severe trauma. The Journal of Trauma. 1990;30(6):695-700 [Pubmed]
    30. Gille P, Bonneville JF, Francois JY, Aubert D, Peltre G, Canal JP. Fracture des pédicules de l'axis chez un nourrisson battu (Fractures of axis pedicles in battered infant). Chirurgie Pediatrique. 1980;21(5):343-344. [Pubmed]
    31. Gipson CL, Tobias JD. Flail chest in a neonate resulting from nonaccidental trauma. Southern Medical Journal. 2006;99(5):536-538 [Pubmed]
    32. Gross RH, Stranger M. Causative factors responsible for femoral fractures in infants and young children. Journal of Pediatric Orthopaedics. 1983;3(3):341-343 [Pubmed]
    33. Haney SB, Boos SC, Kutz TJ, Starling SP. Transverse fracture of the distal femoral metadiaphysis: a plausible accidental mechanism. Pediatric Emergency Care. 2009;25(12):841-844 [Pubmed]
    34. Hechter S, Huyer D, Manson D. Sternal fractures as a manifestation of abusive injury in children. Pediatric Radiology. 2002;32(12):902-906 [Pubmed]
    35. Hinton RY, Lincoln A, Crockett MM, Sponseller P, Smith G. Fractures of the femoral shaft in children. Incidence, mechanisms, and sociodemographic risk factors. Journal of Bone and Joint Surgery (American volume). 1999;81(4):500-509 [Pubmed]
    36. Hiss J, Kahana T. The medicolegal implications of bilateral cranial fractures in infants. The Journal of Trauma: Injury, Infection, and Critical Care. 1995;38(1):32-34 [Pubmed]
    37. Hoskote AU, Martin K, Hormbrey P, Burns EC. Fractures in infants: one in four is non-accidental. Child Abuse Review. 2003;12(6):384-391 [Abstract from Ingenta Connect]
    38. Hui C, Joughin E, Goldstein S, Cooper N, Harder J, Kiefer G, Parsons D, Howard J. Femoral fractures in children younger than three years: the role of nonaccidental injury. Journal of Pediatric Orthopaedics. 2008;28(3):297-302 [Pubmed]
    39. Jaffe AC, Lasser DH. Multiple metatarsal fractures in child abuse. Pediatrics. 1977;60(4 Pt 2):642-643 [Pubmed citation only]
    40. Johnson K, Chapman S, Hall CM. Skeletal injuries associated with sexual abuse. Pediatric Radiology. 2004; 34(8):620-623 [Pubmed]
    41. Jones JC, Feldman KW, Bruckner JD. Child abuse in infants with proximal physeal injuries of the femur. Pediatric Emergency Care. 2004;20(3):157-161 [Pubmed]
    42. Kleinman PK, Marks SC Jr, Richmond JM, Blackbourne BD. Inflicted skeletal injury: a postmortem radiologic-histopathologic study in 31 infants. American Journal of Roentgenology. 1995;165(3):647-650 [Pubmed]
    43. Kleinman PK, Marks SC Jr. A regional approach to classic metaphyseal lesions in abused infants: the distal tibia. American Journal of Roentgenology. 1996:166(5);1207-1212 [Pubmed]
    44. Kleinman PK, Marks SC Jr. A regional approach to the classic metaphyseal lesion in abused infants: the proximal humerus. American Journal of Roentgenology. 1996;167(6):1399-1403 [Pubmed]
    45. Kleinman PK, Marks SC Jr. A regional approach to the classic metaphyseal lesion in abused infants: the proximal tibia. American Journal of Roentgenology. 1996;166(2):421-426 [Pubmed]
    46. Kleinman PK, Marks SC Jr. A regional approach to the classic metaphyseal lesion in abused infants: the distal femur. American Journal of Roentgenology. 1998;170(1):43-47 [Pubmed]
    47. Kleinman PK, Morris NB, Makris J, Moles RL, Kleinman PL. Yield of radiographic skeletal surveys for detection of hand, foot, and spine fractures in suspected child abuse. American Journal of Roentgenology. 2013;200(3):641-4 [Pubmed]

    48. Kleinman PK, Perez-Rossello JM, Newton AW, Feldman HA, Kleinman PL. Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse. American Journal of Roentgenology. 2011;197(4):1005-1008 [Pubmed]
    49. Kleinman PK, Shelton YA. Hangman's fracture in an abused infant: imaging features. Pediatric Radiology. 1997;27(9):776-777 [Pubmed]
    50. Kowal-Vern A, Paxton TP, Ros SP, Lietz H, Fitzgerald M, Gamelli RL. Fractures in the under-3-year-old age cohort. Clinical Pediatrics. 1992;31(11):653-659 [Pubmed]
    51. Leventhal JM, Thomas SA, Rosenfield NS, Markowitz RI. Fractures in young children. Distinguishing child abuse from unintentional injuries. American Journal of Diseases of Children. 1993;147(1):87-92 [Pubmed]
    52. Lindberg DM, Harper NS, Laskey AL, Berger RP; ExSTRA Investigators. Prevalence of abusive fractures of the hands, feet, spine, or pelvis on skeletal survey: perhaps "uncommon" is more common than suggested. Pediatric Emergency Care. 2013;29(1):26-9 [Pubmed]

    53. Loder RT, Feinberg JR. Orthopaedic injuries in children with nonaccidental trauma: demographics and incidence from the 2000 kids' inpatient database. Journal of Pediatric Orthopedics. 2007;27(4):421-426 [Pubmed] (Erratum in Journal of Pediatric Orthopedics. 2008;28(6):699)
    54. McClelland CQ, Heiple KG. Fractures in the first year of life. A diagnostic dilemma. American Journal of Diseases of Children. 1982;136(1):26-29 [Pubmed]
    55. Merten DF, Kirks DR, Ruderman RJ. Occult humeral epiphyseal fracture in battered infants. Pediatric Radiology. 1981;10(3):151-154 [Pubmed]
    56. Meservy CJ, Towbin R, McLaurin RL, Myers PA, Ball W. Radiographic characteristics of skull fractures resulting from child abuse. American Journal of Roentgenology. 1987;149(1):173-175 [Pubmed]
    57. Murphy R, Kelly DM, Moisan A, Thompson NB, Warner WC Jr, Beaty JH, Sawyer JR. Transverse fractures of the femoral shaft are a better predictor of nonaccidental trauma in young children than spiral fractures are. The Journal of Bone and Joint Surgery. American Volume. 2015;97(2):106-111 [Pubmed]

    58. Ng CS, Hall CM. Costochondral junction fractures and intra-abdominal trauma in non-accidental injury (child abuse). Pediatric Radiology. 1998;28(9):671-676 [Pubmed]
    59. Nimkin K, Kleinman PK, Teeger S, Spevak MR. Distal humeral physeal injuries in child abuse: MR imaging and ultrasonography findings. Pediatric Radiology. 1995;25(7):562-565 [Pubmed]
    60. Nimkin K, Spevak MR, Kleinman PK. Fractures of the hands and feet in child abuse: imaging and pathological features. Radiology. 1997;203(1):233-236 [Pubmed]
    61. Ogden JA, Lee KE, Rudicel SA, Pelker RR. Proximal femoral epiphysiolysis in the neonate. Journal of Pediatric Orthopaedics. 1984;4(3):285-292 [Pubmed]
    62. Oral R, Rahhal R, Elshershari H, Menezes AH. Intentional avulsion fracture of the second cervical vertebra in a hypotonic child. Pediatric Emergency Care. 2006;22(5):352-354 [Pubmed]
    63. Pandya NK, Baldwin K, Wolfgruber H, Christian CW, Drummond DS, Hosalkar HS. Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center. Journal of Pediatric Orthopaedics. 2009;29(6):618-625 [Pubmed]
    64. Pandya NK, Baldwin KD, Wolfgruber H, Drummond DS, Hosalkar HS. Humerus fractures in the pediatric population: an algorithm to identify abuse. Journal of Pediatric Orthopaedics: Part B. 2010;19(6):535-541 [Pubmed]
    65. Perez-Rossello JM, Connolly SA, Newton AW, Thomason M, Jenny C, Sugar NF, Kleinman PK. Pubic ramus radiolucencies in infants: the good, the bad, and the indeterminate. American Journal of Roentgenology. 2008;190(6):1481-1486 [Pubmed]
    66. Prendergast NC, de Roux SJ, Adsay NV. Non-accidental pediatric pelvic fracture: a case report. Pediatric Radiology. 1998;28(5):344-346 [Pubmed]
    67. Rao KS, Hyde I. Digital lesions in non-accidental injuries to children. British Journal of Radiology. 1984;57(675):259-260 [Pubmed citation only]
    68. Reece RM, Sege R. Childhood head injuries: accidental or inflicted? Archives of Pediatrics and Adolescent Medicine. 2000;154(1):11-15 [Pubmed]
    69. Renard M, Tridon P, Kuhnast M, Renauld JM, Dollfus P. Three unusual cases of spinal cord injury in childhood. Paraplegia. 1978;16(1):130-134 [Pubmed]
    70. Rex C, Kay PR. Features of femoral fractures in nonaccidental injury. Journal of Pediatric Orthopaedics. 2000;20(3):411-413 [Pubmed]
    71. Rooks VJ, Sisler C, Burton B. Cervical spine injury in child abuse: report of two cases. Pediatric Radiology. 1998;28(3):193-195 [Pubmed]
    72. Rosenberg N, Bottenfield G. Fractures in infants: a sign of child abuse. Annals of Emergency Medicine 1982;11(4):178-180 [Pubmed]
    73. Scherl SA, Miller L, Lively N, Russinoff S, Sullivan CM, Tornetta 3rd. Accidental and nonaccidental femur fractures in children. Clinical Orthopaedics and Related Research. 2000;(376):96-105 [Pubmed]
    74. Schlievert R. Infant mandibular fractures: are you considering child abuse? Pediatric Emergency Care. 2006;22(3):181-183 [Pubmed]
    75. Schweich P, Fleisher G. Rib fractures in children. Pediatric Emergency Care. 1985;1(4):187-189 [Pubmed]
    76. Schwend RM, Werth C, Johnston A. Femur shaft fractures in toddlers and young children: rarely from child abuse. Journal of Pediatric Orthopaedics. 2000;20(4):475-481 [Pubmed]
    77. Shaw BA, Murphy KM, Shaw A, Oppenheim WL, Myracle MR. Humerus shaft fractures in young children: accident or abuse? Journal of Pediatric Orthopaedics. 1997;17(3):293-297 [Pubmed]
    78. Siegel MB, Wetmore RF, Potsic WP, Handler SD, Tom LW. Mandibular fractures in the pediatric patient. Archives of Otolaryngology - Head & Neck Surgery. 1991;117(5):533-536 [Pubmed]
    79. Sieradzki JP, Sarwark JF. Thoracolumbar fracture-dislocation in child abuse: case report, closed reduction technique and review of the literature. Pediatric Neurosurgery.2008;44(3):253-257 [Pubmed]
    80. Skellern CY, Wood DO, Murphy A, Crawford M. Non-accidental fractures in infants: risk of further abuse. Journal of Paediatrics and Child Health. 2000;36(6):590-592 [Pubmed]
    81. Smeets AJ, Robben SG, Meradji M. Sonographically detected costo-chondral dislocation in an abused child. A new sonographic sign to the radiological spectrum of child abuse. Pediatric Radiology. 1990;20(7):566-567 [Pubmed]
    82. Smith FW, Gilday DL, Ash JM, Green MD. Unsuspected costo-vertebral fractures demonstrated by bone scanning in the child abuse syndrome. Pediatric Radiology. 1980;10(2):103-106 [Pubmed]
    83. Starling SP, Heller RM, Jenny C. Pelvic fractures in infants as a sign of physical abuse. Child Abuse and Neglect. 2002;26(5):475-480 [Pubmed]
    84. Stewart G, Meert K, Rosenberg N. Trauma in infants less than three months of age. Pediatric Emergency Care. 1993;9(4):199-201 [Pubmed]
    85. Strait RT, Seigel RM, Shapiro RA. Humeral fractures without obvious etiologies in children less than 3 years of age: when is it abuse? Pediatrics. 1995;96(4 Pt 1):667-671 [Pubmed]
    86. Strouse PJ, Owings CL. Fractures of the first rib in child abuse. Radiology. 1995;197(3):763-765 [Pubmed]
    87. Thomas PS. Rib fractures in infancy. Annales de Radiologie. 1977;20(1):115-122 [Pubmed]
    88. Thomas SA, Rosenfield NS, Leventhal JM, Markovitz RI. Long-bone fractures in young children: distinguishing accidental injuries from child abuse. Pediatrics. 1991;88(3):471-476 [Pubmed]
    89. Tran B, Silvera M, Newton A, Kleinman PK. Inflicted T12 fracture-dislocation: CT/MRI correlation and mechanistic implications. Pediatric Radiology. 2007;37(11):1171-1173 [Pubmed]
    90. Wellington P, Bennet GC. Fractures of the femur in childhood. Injury. 1987;18(2):103-104 [Pubmed]
    91. Worlock P, Stower M, Barbor P. Patterns of fractures in accidental and non-accidental injury in children: a comparative study. British Medical Journal (Clinical Research Edition). 1986;293(6539):100-102 [Pubmed]

 

Epidemiology of fractures

  • Of 540 studies reviewed, eight studies compared abusive and non-abusive fractures 1-8
  • Study design:
    All eight were comparative observational studies
  • Age range: 0 – 12 years

Age

  • 85% of accidental fractures occurred in children over five years of age 8
  • 80% of abusive fractures, occurred in children under 18 months of age 8
  • Three studies examined children under one year of age: 67 abused, 115 non-abused 4,6,7
  • Overall, 25 – 56% of all fractures in children under one year of age were due to abuse 1,4,6,7
  • The highest incidence of abusive fractures was in children under four months of age (p=0.0007) 7
  • Abusive fractures were more common in children less than one year of age than in those older than two years 3

  • In a study of children under 4 years old, the mean age for accidental fractures was 22.1 months (95%CI 21.2, 24.02 months). The mean age of abuse cases was 11.7 months (95%CI 10.6, 12.7 months) 5

  • Children with abusive fractures were significantly younger (p<0.001) 5

Gender

  • One study showed that abusive fractures were more common in boys (p=0.024) 3
  • No gender difference was noted in children aged less than one year 4,6,7
  • No gender difference was found in children aged less than four years (p=0.065) 5

Influence of ethnicity and socio-economic group

  • Two studies analysed by ethnicity 2,3
  • Black children were abused more than white (p<=0.01) 2
  • No difference in ethnicity was found 3
  • No significant differences by socio-economic grouping 3

Multiple fractures

  • Abused children were more likely to have multiple fractures than non-abused children (p<0.001) 3,8
  • One study found no difference 4

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References

  1. Hoskote AU, Martin K, Hormbrey P, Burns EC. Fractures in infants: one in four is non-accidental. Child Abuse Review. 2003;12(6):384-391 [Abstract from Ingenta Connect]
  2. Kowal-Vern A, Paxton TP, Ros SP, Lietz H, Fitzgerald M, Gamelli RL. Fractures in the under-3-year-old age cohort. Clinical Pediatrics. 1992;31(11):653-659 [Pubmed]
  3. Leventhal JM, Thomas SA, Rosenfield NS, Markowitz RI. Fractures in young children. Distinguishing child abuse from unintentional injuries. American Journal of Diseases of Children. 1993;147(1):87-92 [Pubmed]
  4. McClelland CQ, Heiple KG. Fractures in the first year of life. A diagnostic dilemma. American Journal of Diseases of Children. 1982;136(1):26-29 [Pubmed]
  5. Pandya NK, Baldwin K, Wolfgruber H, Christian CW, Drummond DS, Hosalkar HS. Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center. Journal of Pediatric Orthopaedics. 2009;29(6):618-625 [Pubmed]
  6. Rosenberg N, Bottenfield G. Fractures in infants: a sign of child abuse. Annals of Emergency Medicine 1982;11(4):178-180 [Pubmed]
  7. Skellern CY, Wood DO, Murphy A, Crawford M. Non-accidental fractures in infants: risk of further abuse. Journal of Paediatrics and Child Health. 2000;36(6):590-592 [Pubmed]
  8. Worlock P, Stower M, Barbor P. Patterns of fractures in accidental and non-accidental injury in children: a comparative study. British Medical Journal (Clinical Research Edition). 1986;293(6539):100-102 [Pubmed]

 

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