Children younger than 36 months with diaphyseal femur fractures should be evaluated for abuse
Nonaccidental trauma is one of the leading causes of injury and death for children in the United States, with musculoskeletal injuries as one of the most common manifestations of child abuse. As orthopaedic surgeons, we are well-positioned to recognize and diagnose nonaccidental trauma in our smallest, youngest, and most vulnerable patients.

However, the diagnosis of nonaccidental trauma requires proper screening. In 2010, the U.S. Department of Health and Human Services estimated that 2.07 per 100,000 children died as a result of abuse or neglect. Nearly 80 percent of all fractures caused by child abuse occur in those less than 18 months old. The incidence of child abuse is around nine per 1,000 children, with the youngest at highest risk. Other risk factors are first-born children, unplanned pregnancies, premature infants, stepchildren, and handicapped children. Those children with an additional developmental disability have a threefold increased risk of abuse.

Often, the initial presentation of child abuse goes unrecognized. Although skin trauma and bruising are the most common manifestations of abuse, fractures are a close second. Upward of 13 percent of femur fractures in children younger than 3 years of age are secondary to abuse, with an even higher rate among children who have yet to begin walking. In these young patients, orthopaedic surgeons must always be cognizant that child abuse is a possible cause of the injury.

As orthopaedic surgeons, our responsibility to recognize abuse requires an awareness of the specific, physical findings of that abuse.

Detection starts with close examinations
A good history and physical examination are important in these instances. Important details include a good motor development history and details of the event. Ascertain the likelihood the reported mechanism caused the fracture. Vague or inconsistent explanations of how the injury occurred or poor correlation between the stated mechanism and actual injury should raise suspicion. Suspicion should also be raised if there is delay in seeking care. In suspected cases, examine the entire body to look for bruising and other skin manifestations of abuse.

Obtain radiographs of the involved areas. The most common long bone fractures in nonaccidental trauma are the femur and the humerus. If abuse is suspected, order a skeletal survey, which includes specific images of the axial and appendicular skeleton as outlined by the American College of Radiology.

Unsuspected fractures are present in 20 percent of cases of abuse and are most likely discovered on the screening skeletal survey. In more than 70 percent of abused children less than 1 year of age, multiple fractures in different stages of healing were observed. When the initial scans are negative, repeating the skeletal survey a few weeks later increases the likelihood of detection of abuse.

Different fracture patterns can also point to a mechanism of abuse. In respect to diaphyseal femur fractures in children, there is no one specific pattern that is typical of abuse. Transverse, oblique, and spiral fracture patterns can occur in both accidental and nonaccidental trauma. However, when metaphyseal fractures are present, this pattern is highly specific for child abuse and often results from a violent shaking motion to the child's limb or trunk.

Conclusion
We are often the first encounter these children have with the healthcare system. It is critical that we have heightened awareness and sensitivity to nonaccidental trauma. If abuse is suspected, further evaluation is necessary. Nearly all states require providers to report suspected abuse to the local child protective service organization. Remember, a reporter only needs reasonable suspicion, not certainty.

Never forget that not reporting a suspected case can have grave consequences for the patient. Early recognition of abuse is necessary to reduce the mortality associated with this highly preventable condition in our most helpless patients. With a simple evaluation and a more watchful eye, we can prevent future harm.

Bryan Tompkins, MD, received his fellowship training in pediatric orthopaedic surgery at Texas Scottish Rite Hospital for Children in Dallas and currently works as a practicing surgeon for Shriners Hospitals for Children in Spokane, Wash.

Evidence-Based Quality and Value Committee Studies CPG, Identifies Impactful Recommendations
In 2015, the Academy reissued its clinical practice guideline on pediatric diaphyseal femur fractures. Then in 2017, the AAOS Committee on Evidence-Based Quality and Value reviewed the guidelines to determine the most impactful recommendations.

This review of the literature showed the strongest evidence supported the recommendation with the most potential for impact: Children younger than 36 months with diaphyseal femur fractures should be evaluated for child abuse.

Although most femur fractures in children occur as results of unintentional trauma, the committee recognized that children less than 36 months old have an increased chance that the fractures are the result of physical abuse. Three high-quality, population-based studies identified that 12 percent to 14 percent of femur fractures in children less than 3 years old are caused by abuse.

References

1. Coffey C, Haley K, Hayes J, Groner J. The Risk of Child Abuse in Infacnt and Toddler with Lower Extremity Injuries. Journal of Pediatric Surgery. 2005; 40(1):120-123
2. Barber I, Perez-Rossello JM, Wilson CR, Kleinman, P. The Yield of High-Detail Radiographic Skeletal Surveys in Suspected Infant Abuse. Pediatric Radiology. 2015; 45(1):69-80
3. Hinton RY, Lincoln A, Crockett MM, Sponseller P, Smith G. Fractures of the femoral shaft in children. Incidence, mechanisms, and sociodemographic risk factors. J Bone Joint Surg Am. 1999;81:500-509.
4. Loder RT, Feinberg JR. Orthopaedic Injuries in Children with Nonaccidental Trauma: Demographics and Incidence from the 2000 Kids' Inpatient Database. J Pediatr Orthop. 2007;27: 421–426.
5. Miettinen H, Makela EA, Vainio J. The incidence and causative factors responsible for femoral shaft fractures in children. Ann Chir Gynaecol. 1991;80:392-395.
6. Rewers A, Hedegaard H, Lezotte D et al. Childhood femur fractures, associated injuries, and sociodemographic risk factors: a population-based study. Pediatrics. 2005;115:e543-e552.
7. Sink E, Hyman J, Matheny T, Georgopoulus G, Kleinman P. Child Abuse: The Role of the Orthopaedic Surgeon in Nonaccidental Trauma. Clin Orthop Related Res. 2011; 469: 790-797
8. Thomas SA, Rosenfield NS, Leventhal JM, Markowitz RI. Long Bone Fractures in Young Children: Distinguishing Accidental Injuries from Child Abuse. Pediatrics. 1991;88:471–476.
9. US Department of Health and Human Services. ACF, Administration on Children and Families Children's Bureau. www.acf.hhs.gov/programs/cb/