Marie-Louise H J Loos1, Roel Bakx2, J H Allema3, Frank W Bloemers4, Jan A Ten Bosch5, Michael J R Edwards6, Jan B F Hulscher7, Claudia M G Keyzer-Dekker8, Egbert Krug9, Victor A de Ridder10, W Richard Spanjersberg11, Arianne H Teeuw12, Hilco P Theeuwes13, Selena de Vries14, Ralph de Wit15, Rick R van Rijn14,16,17. 1. Department of Paediatric Surgery, Emma Children's Hospital, Paediatric Surgical Centre Amsterdam, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. m.h.loos@amsterdamumc.nl. 2. Department of Paediatric Surgery, Emma Children's Hospital, Paediatric Surgical Centre Amsterdam, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. 3. Department of Surgery, Haga Teaching Hospital & Juliana Children's Hospital, The Hague, The Netherlands. 4. Department of Trauma Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands. 5. Department of Trauma Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands. 6. Department of Trauma Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands. 7. Department of Surgery, Division of Paediatric Surgery, University Medical Centre Groningen, Groningen, The Netherlands. 8. Erasmus Medical Centre, Department of Paediatric Surgery, Sophia Children's Hospital, Rotterdam, The Netherlands. 9. Department of Trauma Surgery, Leiden University Medical Centre, Leiden, The Netherlands. 10. Department of Paediatric Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands. 11. Department of Trauma Surgery, Isala Clinics, Zwolle, The Netherlands. 12. Department of Social Paediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands. 13. Department of Trauma Surgery, Elizabeth TweeSteden Hospital, Tilburg, The Netherlands. 14. Department of Forensic Medicine, Section of Forensic Paediatrics, Netherlands Forensic Institute, The Hague, The Netherlands. 15. Department of Trauma Surgery, Medisch Spectrum Twente, Enschede, The Netherlands. 16. Department of Radiology and Nuclear Medicine, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands. 17. Amsterdam Center for Forensic Science and Medicine, Amsterdam, The Netherlands.
Abstract
BACKGROUND: The prevalence of inflicted femur fractures in young children varies (1.5-35.2%), but these data are based on small retrospective studies with high heterogeneity. Age and mobility of the child seem to be indicators of inflicted trauma. OBJECTIVE: This study describes other factors associated with inflicted and neglectful trauma that can be used to distinguish inflicted and neglectful from accidental femur fractures. MATERIALS AND METHODS: This retrospective study included children (0-6 years) who presented with an isolated femur fracture at 1 of the 11 level I trauma centers in the Netherlands between January 2010 and January 2016. Outcomes were classified based on the conclusions of the Child Abuse and Neglect teams or the court. Cases in which conclusions were unavailable and there was no clear accidental cause were reviewed by an expert panel. RESULTS: The study included 328 children; 295 (89.9%) cases were classified as accidental trauma. Inflicted trauma was found in 14 (4.3%), while 19 (5.8%) were cases of neglect. Indicators of inflicted trauma were age 0-5 months (29%, positive likelihood ratio [LR +] 8.35), 6-12 months (18%, LR + 5.98) and 18-23 months (14%, LR + 3.74). Indicators of neglect were age 6-11 months (18%, LR + 4.41) and age 18-23 months (8%, LR + 1.65). There was no difference in fracture morphology among groups. CONCLUSION: It is unlikely that an isolated femur fracture in ambulatory children age > 24 months is caused by inflicted trauma/neglect. Caution is advised in children younger than 24 months because that age is the main factor associated with inflicted trauma/neglect and inflicted femur fractures.
BACKGROUND: The prevalence of inflicted femur fractures in young children varies (1.5-35.2%), but these data are based on small retrospective studies with high heterogeneity. Age and mobility of the child seem to be indicators of inflicted trauma. OBJECTIVE: This study describes other factors associated with inflicted and neglectful trauma that can be used to distinguish inflicted and neglectful from accidental femur fractures. MATERIALS AND METHODS: This retrospective study included children (0-6 years) who presented with an isolated femur fracture at 1 of the 11 level I trauma centers in the Netherlands between January 2010 and January 2016. Outcomes were classified based on the conclusions of the Child Abuse and Neglect teams or the court. Cases in which conclusions were unavailable and there was no clear accidental cause were reviewed by an expert panel. RESULTS: The study included 328 children; 295 (89.9%) cases were classified as accidental trauma. Inflicted trauma was found in 14 (4.3%), while 19 (5.8%) were cases of neglect. Indicators of inflicted trauma were age 0-5 months (29%, positive likelihood ratio [LR +] 8.35), 6-12 months (18%, LR + 5.98) and 18-23 months (14%, LR + 3.74). Indicators of neglect were age 6-11 months (18%, LR + 4.41) and age 18-23 months (8%, LR + 1.65). There was no difference in fracture morphology among groups. CONCLUSION: It is unlikely that an isolated femur fracture in ambulatory children age > 24 months is caused by inflicted trauma/neglect. Caution is advised in children younger than 24 months because that age is the main factor associated with inflicted trauma/neglect and inflicted femur fractures.