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      Pattern of Fractures in Non-Accidental Injuries in the Pediatric Population in Singapore

      research-article
      , MBBS , , MBBS, , MBBS
      Clinics in Orthopedic Surgery
      The Korean Orthopaedic Association
      Child abuse, Bone fractures, Risk factors, Etiology

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          Abstract

          Background

          Fractures as a result of non-accidental injuries (NAI) are not uncommon among children. The purpose of our study was to describe the incidence, demographic characteristics, and associated risk factors in patients with NAI in a multiethnic Asian cohort.

          Methods

          A retrospective record review of patients admitted to our hospital between September 2007 and 2009 with the diagnosis of NAI was conducted.

          Results

          A total of 978 children were reported with suspicion of NAI. Among them, 570 patients (58.28%) were diagnosed with NAI. Fractures were observed in 35 children (6.14%). NAI fractures were highest among female infants (73.3%). The biological father was the most common known perpetrator of NAI (n = 155, 29.0%). The most common perpetrator sadly remained unknown (n = 14, 40%). All NAI fractures were closed (n = 35, 6.14%), and the most commonly affected bone was the humeral shaft (n = 10, 28.57%) with an oblique configuration. Age < 1 year and parental divorce were significant risk factors associated with these fractures.

          Conclusions

          The skeletal injury pattern and risk factors highlighted in our study will help treating physicians identify patients susceptible to NAI, as many of these patients are young and vulnerable. Protective measures can be initiated early by recognizing these injuries and preventing further physical and psychological harm to the child.

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          Most cited references15

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          Patterns of skeletal fractures in child abuse: systematic review

          Objectives To systematically review published studies to identify the characteristics that distinguish fractures in children resulting from abuse and those not resulting from abuse, and to calculate a probability of abuse for individual fracture types. Design Systematic review. Data sources All language literature search of Medline, Medline in Process, Embase, Assia, Caredata, Child Data, CINAHL, ISI Proceedings, Sciences Citation, Social Science Citation Index, SIGLE, Scopus, TRIP, and Social Care Online for original study articles, references, textbooks, and conference abstracts until May 2007. Study selection Comparative studies of fracture at different bony sites, sustained in physical abuse and from other causes in children <18 years old were included. Review articles, expert opinion, postmortem studies, and studies in adults were excluded. Data extraction and synthesis Each study had two independent reviews (three if disputed) by specialist reviewers including paediatricians, paediatric radiologists, orthopaedic surgeons, and named nurses in child protection. Each study was critically appraised by using data extraction sheets, critical appraisal forms, and evidence sheets based on NHS Centre for Reviews and Dissemination guidance. Meta-analysis was done where possible. A random effects model was fitted to account for the heterogeneity between studies. Results In total, 32 studies were included. Fractures resulting from abuse were recorded throughout the skeletal system, most commonly in infants (<1 year) and toddlers (between 1 and 3 years old). Multiple fractures were more common in cases of abuse. Once major trauma was excluded, rib fractures had the highest probability for abuse (0.71, 95% confidence interval 0.42 to 0.91). The probability of abuse given a humeral fracture lay between 0.48 (0.06 to 0.94) and 0.54 (0.20 to 0.88), depending on the definition of abuse used. Analysis of fracture type showed that supracondylar humeral fractures were less likely to be inflicted. For femoral fractures, the probability was between 0.28 (0.15 to 0.44) and 0.43 (0.32 to 0.54), depending on the definition of abuse used, and the developmental stage of the child was an important discriminator. The probability for skull fractures was 0.30 (0.19 to 0.46); the most common fractures in abuse and non-abuse were linear fractures. Insufficient comparative studies were available to allow calculation of a probability of abuse for other fracture types. Conclusion When infants and toddlers present with a fracture in the absence of a confirmed cause, physical abuse should be considered as a potential cause. No fracture, on its own, can distinguish an abusive from a non-abusive cause. During the assessment of individual fractures, the site, fracture type, and developmental stage of the child can help to determine the likelihood of abuse. The number of high quality comparative research studies in this field is limited, and further prospective epidemiology is indicated.
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            Racial differences in the evaluation of pediatric fractures for physical abuse.

            Child maltreatment is a significant problem within US society, and minority children have higher rates of substantiated maltreatment than do white children. However, it is unclear whether minority children are abused more frequently than whites or whether their cases are more likely to be reported. To determine whether there are racial differences in the evaluation and Child Protective Services (CPS) reporting of young children hospitalized for fractures. Retrospective chart review conducted at an urban US academic children's hospital among 388 children younger than 3 years hospitalized for treatment of an acute primary skull or long-bone fracture between 1994 and 2000. Children with perpetrator-admitted child abuse, metabolic bone disease, birth trauma, or injury caused by vehicular crash were excluded. Ordering of skeletal surveys and filing reports of suspected abuse. Reports of suspected abuse were filed for 22.5% of white and 52.9% of minority children (P<.001). Abusive injuries, as determined by expert review, were more common among minority children than among white children (27.6% vs 12.5%; P<.001). Minority children aged at least 12 months to 3 years (toddlers) were significantly more likely to have a skeletal survey performed compared with their white counterparts, even after controlling for insurance status, independent expert determination of likelihood of abuse, and appropriateness of performing a skeletal survey (adjusted odds ratio [OR], 8.75; 95% confidence interval [CI], 3.48-22.03; P<.001). This group of children was also more likely to be reported to CPS compared with white toddlers, even after controlling for insurance status and likelihood of abuse (adjusted OR, 4.32; 95% CI, 1.63-11.43; P =.003). By likelihood of abuse, differential ordering of skeletal surveys and reporting of suspected abuse were most pronounced for children at least 12 months old with accidental injuries; however, differences were also noted among toddlers with indeterminate injuries but not among infants or toddlers with abusive injuries. Minority children at least 12 months old with accidental injuries were more than 3 times more likely than their white counterparts to be reported for suspected abuse (for children with Medicaid or no insurance, relative risk [RR], 3.08; 95% CI, 1.37-4.80; for children with private insurance, RR, 3.74; 95% CI, 1.46-6.01). While minority children had higher rates of abusive fractures in our sample, they were also more likely to be evaluated and reported for suspected abuse, even after controlling for the likelihood of abusive injury. This suggests that racial differences do exist in the evaluation and reporting of pediatric fractures for child abuse, particularly in toddlers with accidental injuries.
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              Patterns of fractures in accidental and non-accidental injury in children: a comparative study.

              The incidence and pattern of fractures in children who had been abused were compared with those of fractures sustained by children of similar ages in whom abuse had been excluded. From 1976 to 1982 there were 35 children with fractures resulting from child abuse, and all were aged under 5. Of the 826 children in the control group, seen from January to June 1981, 85% were aged over 5. Abused children were much more likely to have multiple fractures (p less than 0.001) and bruising of the head and neck (p less than 0.001). Fractures of the ribs were common in children who had been abused, and their presence, in the absence of major chest trauma, strongly suggested that abuse was occurring. Injuries to the long bones were invariably spiral or oblique fractures or subperiosteal new bone formation--both "gripping or twisting" injuries. Spiral fracture of the humeral shaft was significantly more common (p less than 0.001) in the group of abused children. Classic metaphyseal chip fractures were uncommon. One child in eight aged under 18 months who sustains a fracture may be a victim of child abuse.
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                Author and article information

                Journal
                Clin Orthop Surg
                Clin Orthop Surg
                CIOS
                Clinics in Orthopedic Surgery
                The Korean Orthopaedic Association
                2005-291X
                2005-4408
                December 2014
                10 November 2014
                : 6
                : 4
                : 432-438
                Affiliations
                Department of Orthopaedics Surgery, KK Women's and Children's Hospital, Singapore.
                Author notes
                Correspondence to: Sumanth Kumar Gera, MBBS. Department of Orthopaedics Surgery, KK Women's and Children's Hospital, Level 4, Children's Tower, Singapore 229899. Tel: +65-63942171, Fax: +65-62919232, Sumanth.Kumar@ 123456kkh.com.sg
                Article
                10.4055/cios.2014.6.4.432
                4233223
                47ef4c81-6012-4b2d-b166-c7095ac52f6e
                Copyright © 2014 by The Korean Orthopaedic Association

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 07 February 2014
                : 28 April 2014
                Categories
                Original Article

                Surgery
                child abuse,bone fractures,risk factors,etiology
                Surgery
                child abuse, bone fractures, risk factors, etiology

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