Kemp, A. M., F. Dunstan, et al. (2008). Patterns of skeletal fractures in child abuse: Systematic review. British Medical Journal, 337(7674), 1-8.
Childhood fractures are common but only the minority of these are related to child abuse. How can clinicians identify which fractures have been caused by abuse? This systematic review of published literature sought to identify characteristics that distinguish abusive fractures from non-abusive ones in young children.
Thirty-two studies were included in this paper after systematically reviewing the world literature on comparison of abusive and non-abusive fractures. The results demonstrated that abusive fractures can be found in all bones of the body and that "no fracture on its own can be used to diagnose child abuse". However, rib fractures carried a 71% probability of being abusive, regardless of their location (anterior, posterior, or lateral). The likelihood of fractures of the humerus (upper arm) being attributable to abuse was 48%, and was higher in children less than 15 months of age. Spiral and oblique fractures of the humerus were more commonly seen with abuse than non-abuse injuries. The probability of a femur (upper leg) fracture being attributable to child abuse was 28% but was higher in young children who were not yet walking. No specific type (eg. spiral) or location of femur fracture was indicative of an abusive or non-abusive mechanism of injury. Skull fractures were reported to be the most common abuse and non-abuse fracture in children under 3 years of age. Overall, the probability of this common fracture being attributable to abuse was 30% and there were no features of the fracture that were consistently reported to distinguish between the two groups.
This review confirms prior reports demonstrating that most abusive fractures occur in infants and toddlers (primarily less than 18 months of age) and most non-abusive fractures occur in school age children (primarily over 5 years of age). Abuse is a common cause of fractures in very young children, representing 25-56% of all fractures in children less than 1 year of age. This study also demonstrated that multiple fractures are significantly associated with abuse, in the absence of bone fragility disorders and major non-abusive trauma (eg. motor vehicle collisions).
Thirty-two studies were included for analysis after a systematic review of the world literature. This was completed by searching 14 science and social science databases, textbooks and conference proceedings, and identifying articles from other sources. Studies were included if they reported on the distribution of radiographically proven fractures in children less than 18 years of age and they compared fractures caused by physical abuse with those caused by non-abusive means. Fractures from motor vehicle collisions and surgery were excluded from analysis, as were articles which were not empirical studies or those with significant design flaws (e.g., bias, case attrition, confounding factors, incomplete ascertainment, inadequate definition for abuse). Articles were reviewed by 2 or more members of the Welsh Child Protection Systematic Review Group using standardized tools based on recommendations from the NHS Centre for Reviews and Dissemination. Where indicated, meta-analysis was used to generate probabilities of abuse for each bone. Studies were classified according to the certainty of abuse and non-abuse and a random effects model was used to account for the heterogeneity. Descriptive analysis of some features of fracture sites was also included.