Skeletal Survey Yield in Young Children with Femur Fractures

Background: Fractures are common in children, and it can be difficult to distinguish unintentional injuries from child abuse. Objective: We describe circumstances of injury, prevalence of suspicion for physical abuse, and use of imaging to identify additional occult fractures in young children with femur fractures. Methods: We reviewed the medical records for children younger than 48 months old with femur fractures treated at a pediatric referral hospital (2011–2013). We abstracted age, ambulation, injury circumstances, bruising, head trauma, additional fractures, and determination of injury suspicious for abuse. Results: In 22 of 127 (17%) children with femur fractures, there was strong suspicion for physical abuse. Infants ≤ 12 months old accounted for 19 of 22 (86%) of those with suspicious injuries. In 2 of 22 (9%) with suspected abuse, the child could walk independently. In 8 of 22 (36%) with suspicious injuries, an injury event was reported as directly witnessed versus 50 of 105 (48%) of the unintentional injuries. Six of 22 (27%) with suspicious injuries had bruises versus 11 of 105 (10%) with unintentional injuries (χ², p < 0.03). Four of 22 (18%) children with suspicious injuries had head trauma, versus 0 of 105 with unintentional injuries. Of the 8 with occult fractures identified on a skeletal survey (designated suspicious for abuse), all were ≤ 12 months old and none were walking independently. Conclusions: Most children with femur fractures suspicious for abuse were ≤ 12 months old and not walking independently. Skeletal surveys identified additional fractures in 7% of children, and were useful in the forensic evaluation of non-ambulatory children ≤ 12 months old.