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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 for femoral fractures

  • Study designs:
    16 cross-sectional 1,5-8,10,12,15-17,22-27
    4 case-control 3,20,21,28
    1 cohort 13
    7 case series 2,4,9,11,14,18,19

 

  • Age range: 0-16 years (0 – 20 years in one study 17)
  • No study addressed disabled children
  • Influence of ethnicity and socio-economic group: no difference in socio-economic status was reported in one study 3

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References

  1. Anderson WA. The significance of femoral fractures in children. Annals of Emergency Medicine. 1982;11(4):174-177 [Pubmed]
  2. 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]
  3. 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]
  4. 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]

  5. Beals RK, Tufts E. Fractured femur in infancy: the role of child abuse. Journal of Pediatric Orthopaedics. 1983;3(5):583-586 [Pubmed]
  6. 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]
  7. 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]
  8. 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]
  9. 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]
  10. 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]
  11. 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]
  12. 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]
  13. 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]
  14. 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]
  15. 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]
  16. 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]
  17. 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)
  18. 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]

  19. Ogden JA, Lee KE, Rudicel SA, Pelker RR. Proximal femoral epiphysiolysis in the neonate. Journal of Pediatric Orthopaedics. 1984;4(3):285-292 [Pubmed]
  20. 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]
  21. Rex C, Kay PR. Features of femoral fractures in nonaccidental injury. Journal of Pediatric Orthopaedics. 2000;20(3):411-413 [Pubmed]
  22. Rosenberg N, Bottenfield G. Fractures in infants: a sign of child abuse. Annals of Emergency Medicine 1982;11(4):178-180 [Pubmed]
  23. 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]
  24. 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]
  25. 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]
  26. 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]
  27. Wellington P, Bennet GC. Fractures of the femur in childhood. Injury. 1987;18(2):103-104 [Pubmed]
  28. 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]

Meta-analysis

  • Of the studies included up to 2012, 13 were suitable for meta-analysis 1,3-8,10-15
  • Since 2013, the meta-analysis is sub-divided into children aged 0-18 months with confirmed or suspected abuse 1,2,5,7,9,11,13-15 and children aged 12-48 months with confirmed or suspected abuse 1,2,4,7,13-15
  • For children aged 0-18 months there was no heterogeneity between studies (I2=0%) and the positive predictive value (PPV) for suspected or confirmed abuse when a femoral fracture is present is 51.1% (95% confidence interval 34.1-66.1)
  • For children aged 12-48 months there was moderate heterogeneity present between studies (I2=57.4%) and a far lower PPV of 11.7% (95% confidence interval 6.1-17.3)
  • This is consistent with the observation that children who are not independently mobile are far less likely to sustain an accidental femoral fracture 13

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References

  1. Anderson WA. The significance of femoral fractures in children. Annals of Emergency Medicine. 1982;11(4):174-177 [Pubmed]
  2. 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]
  3. Beals RK, Tufts E. Fractured femur in infancy: the role of child abuse. Journal of Pediatric Orthopaedics. 1983;3(5):583-586 [Pubmed]
  4. 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]
  5. 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]
  6. 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]
  7. 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]
  8. 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]
  9. 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]
  10. 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]
  11. Rosenberg N, Bottenfield G. Fractures in infants: a sign of child abuse. Annals of Emergency Medicine 1982;11(4):178-180 [Pubmed]
  12. 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]
  13. 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]
  14. 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]
  15. Wellington P, Bennet GC. Fractures of the femur in childhood. Injury. 1987;18(2):103-104 [Pubmed]

 

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