Fractured femur in infancy: the role of child abuse.

Analysis of 80 femoral fracture episodes in children under 4 years of age revealed that 8.5% were due to violent trauma, 12.5% were "pathologic" fractures, 30% were related to child abuse, and 49% resulted from normal trauma to normal children. Child abuse as a cause of femoral fracture is more common in children under 1 year of age, first-born children, those with preexisting brain damage, and those with bilateral fractures. The fracture configuration was not usually pathognomonic of abuse, although fractures at the subtrochanteric level and chip fracture of the distal metaphysis were more common in abused children. This study suggests that if there is a reasonable history of cause of fracture, appropriate timing in seeking medical care, and no evidence of additional trauma, further evaluation will not be likely to provide evidence of abuse. If any of these criteria is lacking, a skeletal survey and further evaluation are indicated.