Who are we missing? Too few skeletal surveys for children with humeral and femoral fractures

Abstract

Aim: To determine the potential shortfall in skeletal survey referral for children presenting with an acute non-supracondylar humeral or femoral fracture.

Materials and methods: Plain radiograph reports were reviewed retrospectively using the radiology information system database over a 5 year study period (May 2008-2013) in children under 18 months of age who presented with an acute fracture. Subsequent skeletal survey referral was used as a surrogate marker for further investigation of child abuse. Application of robust meta-analysis derived probability data regarding likelihood of child abuse as a cause of non-supracondylar humeral or femoral fracture was applied. An estimation of the expected number of cases of abuse, with shortfall in skeletal survey referrals, was then calculated.

Results: There were 288 fractures in 281 children. Three children presented with multiple fractures and were considered separately in the present data. The mean patient age was 10.5 months. Nine (3%) non-supracondylar humeral fractures were identified of which four cases may have been due to non-accidental injury (NAI). One (11%) of these patients was referred for a skeletal survey indicating a potential shortfall of three referrals. Twenty-five (9%) femoral fractures were identified of which 13 cases may have been due to NAI, with six (24%) referrals for skeletal surveys generated. This indicates a potential shortfall of seven referrals.

Conclusion: The present study serves as a current analysis of practice within a tertiary paediatric referral centre. There appeared to be local under-investigation of NAI. Improved child protection education and awareness programmes have now been introduced.