Incomplete Fractures of Distal Long Bones Among Children in Early Stages of Mobility: Few Concerns for Physical Child Abuse at a Single Pediatric Level I Trauma Center

Holly Hughes Garza; Qais Zai; Dhvani Shanghvi; Karla A Lawson; Christopher D Souder

doi:10.1097/PEC.0000000000003132

Incomplete Fractures of Distal Long Bones Among Children in Early Stages of Mobility: Few Concerns for Physical Child Abuse at a Single Pediatric Level I Trauma Center

Pediatr Emerg Care. 2024 Feb 14. doi: 10.1097/PEC.0000000000003132. Online ahead of print.

Authors

Holly Hughes Garza¹, Qais Zai², Dhvani Shanghvi, Karla A Lawson, Christopher D Souder³

Affiliations

¹ From the Dell Children's Medical Center, Trauma and Injury Research Center, Austin, TX.
² The University of Texas Dell Medical School, Austin, TX.
³ Department of Surgery and Perioperative Care, The University of Texas Dell Medical School, Austin, TX.

PMID: 38355139
DOI: 10.1097/PEC.0000000000003132

Abstract

Objectives: This study aimed to describe the characteristics, reported mechanism of injury, fracture morphology, and level of physical abuse concern among children in the early stages of mobility diagnosed with an incomplete distal extremity long bone fracture.

Methods: A retrospective chart review was performed for all children aged 10 to 12 months with an incomplete fracture of a distal forearm or distal lower limb who were reportedly pulling up, cruising, or ambulating, and who were evaluated by the child abuse pediatrics team at a single pediatric level I trauma center.

Results: Of the 29 patients who met inclusion criteria, the child abuse pediatrics team had concerns about physical child abuse for 3 children. Not every case with an unknown or discrepant history of injury was deemed concerning for abuse, but all 3 for whom the team determined that concern was warranted had an unknown or discrepant history. All 3 of these children had distal forearm fractures; 1 child had multiple concomitant fractures (including a scapular fracture), and 2 had evidence of bone healing at initial presentation. Each of these observations raises concern for abusive injury based on current evidence. Both-bone buckle fractures of the radius/ulna and tibia/fibula were the most common type of incomplete distal fracture.

Conclusions: This age group presents a unique challenge when designing evidence-based algorithms for the detection of occult injuries in emergency departments. Incomplete fractures of a distal limb are commonly related to a fall and may be considered "low specificity" for physical abuse. However, some publications conclude they should prompt universal physical abuse screening. Our small study indicated that the presence or absence of certain risk factors may provide additional information which could help guide the need for a more thorough evaluation for occult injury in early-mobile children with incomplete distal extremity long bone fractures. Ongoing research is warranted.