Femur Fractures in the Pediatric Population: Abuse or Accidental Trauma?

Child abuse represents a serious threat to the health and well-being of the pediatric population. Orthopaedic specialists will often become involved when child abuse is suspected as a result of the presence of bony injury. Distinguishing abuse from accidental trauma can be difficult and is often based on clinical suspicion. We sought to determine whether accidental femur fractures in pediatric patients younger than age 4 could be distinguished from child abuse using a combination of presumed risk factors from the history, physical examination findings, radiographic findings, and age. We searched our institution's SCAN (Suspected Child Abuse and Neglect) and trauma databases. We identified 70 patients in whom the etiology of their femur fracture was abuse and compared that group with 139 patients who had a femur fracture in whom accidental trauma was the etiology. A history suspicious for abuse, physical or radiographic evidence of prior injury, and age younger than 18 months were risk factors for abuse. Patients with no risk factors had a 4% chance, patients with one risk factor had a 29% chance, patients with two risk factors had an 87% chance, and patients with all three risk factors had a 92% chance of their femur fracture being a result of abuse. Clinicians can use this predictive model to guide judgment and referral to social services when seeing femur fractures in very young children in the emergency room. Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.