Fractures in young children. Distinguishing child abuse from unintentional injuries

J. M. Leventhal, S. A. Thomas, N. S. Rosenfield and R. I. Markowitz
Department of Pediatrics, Yale University School of Medicine, New Haven, Conn. 06510.

OBJECTIVE--To determine features of fractures in young children that would be helpful in distinguishing child abuse from unintentional injuries. DESIGN--Case series. SETTING--Pediatric Services of Yale-New Haven (Conn) Hospital (a tertiary care center). PATIENTS--Consecutive children who were less than 3 years of age and who were examined for a fracture from January 1979 through December 1983 were identified from the daily logs of the emergency department or the hospital's child abuse registry. OUTCOME MEASURE--Each case was rated, by means of predefined criteria and a consensus of two clinicians and two pediatric radiologists, on a seven-point scale from "definite child abuse" to "definite unintentional injury." A middle rating of "unknown" was used if there was not enough information to reach a consensus. RESULTS--Of the 253 fractures in 215 children that were identified, we categorized 24.2% as abuse, 8.4% as unknown, and 67.4% as unintentional injuries. Fractures that were considered likely due to abuse were (1) fractures in children whose caretakers reported either a change in the child's behavior, but no accidental event, or a minor fall, but the injury was more severe than expected; (2) fractures of the radius/ulna, tibia/fibula, or femur in children less than 1 year of age; or (3) midshaft or metaphyseal fractures of the humerus. Linear fractures of the parietal bone were the most common skull fractures, whether due to abuse or unintentional injuries. CONCLUSION--In young children with fractures, child abuse is common. By comparing fractures due to abuse and those due to unintentional injuries, we obtained empiric evidence to help clinicians and radiologists correctly examine children with such serious injuries.

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