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Investigators from Children’s Mercy Hospital, Kansas City, MO, conducted a retrospective study to compare the rates of concomitant suspicious injuries (CSI) among young, mobile children presenting with fractures that are presumed to be low-risk for abuse on whom a skeletal survey (SS) was obtained, and to determine the rate of occult fractures that are presumed to be low-risk among young children on whom an SS was obtained for any reason. Study participants were identified from a larger retrospective study that included children <2 years old who received a SS at Children’s Mercy Hospital between 2012 and 2016. The current analysis was limited to patients in the larger study who were 9 to 23 months old. Demographic information and radio-graphic findings were obtained from medical records. Fractures classified as low-risk included extremity buckle, supracondylar humerus, clavicle, and toddler’s fractures. Rib, sternal, and spine fractures were classified as high-risk, and other fractures were classified as moderate-risk. Children presenting with a skull fracture or as the only fracture identified on SS were excluded from the analyses. CSI were defined as non-index injury that was identified by occult injury screening (SS, neuroimaging, abdominal CT, etc), high-risk bruising, or other high-risk injury. Odds ratios were calculated to compare rates of any CSI and specific types of CSI among children presenting with low- or medium-risk fractures. Among children with a SS performed for any reason, rates of different types of occult fractures were determined and classified as low or non-low risk for abuse based on location and type of fracture.
A total of 201 eligible children on whom SS were obtained had a fracture present. These numbers include 158 patients who presented with fractures, with 58 having low-risk, 92 moderate-risk, and 8 high-risk fractures. Among those with low-risk fractures, 8 (14%) had a CSI, including 5 with an additional occult fracture and 3 with high-risk bruising. Rates of CSI were 13% in children with moderate-risk and 50% in those with high-risk fractures. Compared to those with moderate-risk fractures, rates of any CSI were similar in children with low-risk fractures (OR, 0.9; 95% CI, 0.4, 2.5). There also were no significant differences between groups for rates of occult fractures (OR, 0.6; 95% CI, 0.2, 2.2) or high-risk bruising (OR, 0.8; 95% CI, 0.2, 3.9). There were 45 children with a total of 59 occult fractures identified by SS. The overall most common type of occult fracture was rib (27%). There were 19 low-risk occult fractures identified, including 10 (22%) buckle, 4 (9%) clavicle, 3 (7%) toddler’s, and 2 (4%) supracondylar fractures.
The authors conclude that presumed low-risk fractures were sometimes associated with signs of abuse in children who had a SS performed.
Dr Bechtel has disclosed no...
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