Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center.

BACKGROUND:
Child abuse is a serious threat to the physical and psychosocial well-being of the pediatric population. Musculoskeletal injuries are common manifestations of child abuse. There have been multiple studies that have attempted to identify the factors associated with, and the specific injury patterns seen with musculoskeletal trauma from child abuse, yet there have been no large studies that have used prospectively collected data and controlled comparisons. The purpose of our study was to describe the patterns of orthopaedic injury for child abuse cases detected in the large urban area that our institution serves, and to compare the injury profiles of these victims of child abuse to that of general (accidental) trauma patients seen in the emergency room and/or hospitalized during the same time period.

METHODS:
This study is a retrospective review of prospectively collected information from an urban level I pediatric trauma center. Five hundred cases of child abuse (age birth to 48 mo) were identified by membership in our institution's Suspected Child Abuse and Neglect database collected between 1998 and 2007. These cases were compared against 985 general trauma (accidental) control patients of the same age group from 2000 to 2003. Age, sex, and injury type were compared.

RESULTS:
Victims of child abuse were on average younger than accidental trauma patients in the cohort of patients under 48 months of age. There was no difference in sex distribution between child abuse and accidental trauma patients. When the entire cohort of patients under 48 months were examined after adjusting for age and sex, the odds of rib (14.4 times), tibia/fibula (6.3 times), radius/ulna (5.8 times), and clavicle fractures (4.4 times) were significantly higher in child abuse versus accidental trauma patients. When regrouping the data based on age, in patients younger than 18 months of age, the odds of rib (23.7 times), tibia/fibula (12.8 times), humerus (2.3 times), and femur fractures (1.8 times) were found to be significantly higher in the child abuse group. Yet, in the more than 18 months age group, the risk of humerus (3.4 times) and femur fractures (3.3 times) was actually higher in the accidental trauma group than in the child abuse group.

CONCLUSIONS:
Patients who present to an urban level I pediatric trauma center and are victims of abuse are generally younger, and have an equal propensity to be male or female. It is important for the clinician to recognize that the age of the patient (younger or older than 18 mo and/or walking age) is an important determinant in identifying injury patterns suspicious for abuse. Patients below the age of 18 months who present with rib, tibia/fibula, humerus, or femur fractures are more likely to be victims of abuse than accidental trauma patients. Yet, when patients advance in age beyond 18 months, their presentation with long bone fractures (ie, femur and humerus) is more likely to be related to accidental trauma than child abuse.

LEVEL OF EVIDENCE:
level III, prognostic study.