title: Patterns of skeletal fractures in child abuse: systematic review.
abstract: OBJECTIVE
  To systematically review published studies to identify the characteristics that distinguish fractures in children resulting from abuse and those not resulting from abuse, and to calculate a probability of abuse for individual fracture types.
  
  
  METHODS
  Systematic review.
  
  
  METHODS
  All language literature search of Medline, Medline in Process, Embase, Assia, Caredata, Child Data, CINAHL, ISI Proceedings, Sciences Citation, Social Science Citation Index, SIGLE, Scopus, TRIP, and Social Care Online for original study articles, references, textbooks, and conference abstracts until May 2007.
  
  
  METHODS
  Comparative studies of fracture at different bony sites, sustained in physical abuse and from other causes in children <18 years old were included. Review articles, expert opinion, postmortem studies, and studies in adults were excluded. Data extraction and synthesis Each study had two independent reviews (three if disputed) by specialist reviewers including paediatricians, paediatric radiologists, orthopaedic surgeons, and named nurses in child protection. Each study was critically appraised by using data extraction sheets, critical appraisal forms, and evidence sheets based on NHS Centre for Reviews and Dissemination guidance. Meta-analysis was done where possible. A random effects model was fitted to account for the heterogeneity between studies.
  
  
  RESULTS
  In total, 32 studies were included. Fractures resulting from abuse were recorded throughout the skeletal system, most commonly in infants (<1 year) and toddlers (between 1 and 3 years old). Multiple fractures were more common in cases of abuse. Once major trauma was excluded, rib fractures had the highest probability for abuse (0.71, 95% confidence interval 0.42 to 0.91). The probability of abuse given a humeral fracture lay between 0.48 (0.06 to 0.94) and 0.54 (0.20 to 0.88), depending on the definition of abuse used. Analysis of fracture type showed that supracondylar humeral fractures were less likely to be inflicted. For femoral fractures, the probability was between 0.28 (0.15 to 0.44) and 0.43 (0.32 to 0.54), depending on the definition of abuse used, and the developmental stage of the child was an important discriminator. The probability for skull fractures was 0.30 (0.19 to 0.46); the most common fractures in abuse and non-abuse were linear fractures. Insufficient comparative studies were available to allow calculation of a probability of abuse for other fracture types.
  
  
  CONCLUSIONS
  When infants and toddlers present with a fracture in the absence of a confirmed cause, physical abuse should be considered as a potential cause. No fracture, on its own, can distinguish an abusive from a non-abusive cause. During the assessment of individual fractures, the site, fracture type, and developmental stage of the child can help to determine the likelihood of abuse. The number of high quality comparative research studies in this field is limited, and further prospective epidemiology is indicated.
authors.affiliation: Welsh Child Protection Systematic Review Group, Clinical Epidemiology Interdisciplinary Research Group, School of Medicine, Cardiff University, University Hospital of Wales Heath Park, Cardiff CF 2XX. kempam@cf.ac.uk
authors.forename: Alison M
authors.initials: AM
authors.lastname: Kemp
authors.forename: Frank
authors.initials: F
authors.lastname: Dunstan
authors.forename: Sara
authors.initials: S
authors.lastname: Harrison
authors.forename: Susan
authors.initials: S
authors.lastname: Morris
authors.forename: Mala
authors.initials: M
authors.lastname: Mann
authors.forename: Kim
authors.initials: K
authors.lastname: Rolfe
authors.forename: Shalini
authors.initials: S
authors.lastname: Datta
authors.forename: D Phillip
authors.initials: DP
authors.lastname: Thomas
authors.forename: Jonathan R
authors.initials: JR
authors.lastname: Sibert
authors.forename: Sabine
authors.initials: S
authors.lastname: Maguire
mesh_terms: D000293:Adolescent; D001134:Arm Injuries / Q000209:etiology*; D002648:Child; D002649:Child Abuse / Q000175:diagnosis*; D002675:Child, Preschool; D050723:Fractures, Bone / Q000209:etiology*; D006801:Humans; D007223:Infant; D007869:Leg Injuries / Q000209:etiology*; D012253:Rib Fractures / Q000209:etiology*; D012887:Skull Fractures / Q000209:etiology*