Tibial fractures in very young children and child abuse
Report by Rob Williams, Specialist Registrar
Checked by N Hardcastle, Senior House Officer
Institution Manchester Royal Infirmary
Abstract
A short cut review was carried out to establish whether tibial fractures in very young children are associated with child abuse. 44 papers were found using the reported searches, of which three presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that very young children with tibial fractures should be closely assessed for non‐accidental injury.
Clinical scenario
An 18 month old child attends the emergency department with a limp. You question the mother of the child who explains that the child has fallen down three stairs at home. X‐ray reveals a transverse tibial fracture. Further inquiry is unrewarding, and you wonder whether the presence of the fracture alone is sufficient to support a diagnosis of non‐accidental injury.
Three‐part question
In [very young children who present with tibial fractures] what are [the relative chances of accidental and non‐accidental injury]?
Search strategy
EMBASE<1980 to 2006 Week 12 Ovid MEDLINE(R)<1966 to March Week 3 2006 (exp battered child syndrome OR battered child syndrome.mp OR child abuse OR non‐accidental injury.mp OR non‐accidental trauma.mp) AND (exp tibial fractures OR transverse tibial fracture$.mp OR spiral tibial fracture$.mp) LIMIT to human AND English. The Cochrane Library 2006, Issue 1 [Child abuse [MeSH]] AND [tibial fractures [MeSH]] – 0 results.
Search outcome
Altogether 44 papers were found, of which three were of some relevance to the question. These are shown in table 4.
Table 4.
| Author, date and country | Patient group | Study type | Outcomes | Key results | Study weaknesses |
|---|---|---|---|---|---|
| Mellick LB, et al, 1990, USA | 10 children aged <4 years with isolated spiral tibial fractures | Case series | Number of non accidental injuries | 1 (10%) | Small series subject to inclusion bias |
| Banaszkiewicz PA, et al, 2002, UK | 5 children aged <1 year with tibial fractures | Retrospective survey | Definite abuse | 1 (20%) | Very small number of tibial fractures in the study |
| Likely abuse | 1 (20%) | ||||
| Suspicious of abuse | 1 (20%) | Retrospective assessment of abuse risk | |||
| Coffey C et al, 2005, USA | 26 children aged ⩽18 months with tibial fractures | Retrospective survey | Abuse | 25 (96%) | Small number of cases from a large survey |
Comment(s)
The numbers of children with the target condition (tibial fracture) in the case series is small. However in the cases found there seems to be a clear link between tibial fractures in very young children (aged 18 months or less) and non‐accidental injury.
Clinical bottom line
Very young children with tibial fractures should be closely assessed for non‐accidental injury
References
- Mellick L B, Reesor K. Spiral tibial fractures of children: a commonly accidental spiral long bone fracture. American Journal of Emergency Medicine 1990 May;8(3):234-7. [DOI] [PubMed] [Google Scholar]
- Banaszkiewicz P A, Scotland T R, Myerscough E J. Fractures in children younger than age 1 year: Importance of collaboration with child protection services. Journal of Pediatric Orthopedics 2002;22(6):740-744. [PubMed] [Google Scholar]
- Coffey C, Haley K, Hayes J.et al. The risk of child abuse in infants and toddlers with lower extremity injuries. Journal of Pediatric Surgery 2005;40(1):120-123. [DOI] [PubMed] [Google Scholar]