Delayed identification of pediatric abuse-related fractures.
OBJECTIVE
Because physicians may have difficulty distinguishing accidental fractures from those that are caused by abuse, abusive fractures may be at risk for delayed recognition; therefore, the primary objective of this study was to determine how frequently abusive fractures were missed by physicians during previous examinations. A secondary objective was to determine clinical predictors that are associated with unrecognized abuse.


METHODS
Children who were younger than 3 years and presented to a large academic children's hospital from January 1993 to December 2007 and received a diagnosis of abusive fractures by a multidisciplinary child protective team were included in this retrospective review. The main outcome measures included the proportion of children who had abusive fractures and had at least 1 previous physician visit with diagnosis of abuse not identified and predictors that were independently associated with missed abuse.


RESULTS
Of 258 patients with abusive fractures, 54 (20.9%) had at least 1 previous physician visit at which abuse was missed. The median time to correct diagnosis from the first visit was 8 days (minimum: 1; maximum: 160). Independent predictors of missed abuse were male gender, extremity versus axially located fracture, and presentation to a primary care setting versus pediatric emergency department or to a general versus pediatric emergency department.


CONCLUSIONS
One fifth of children with abuse-related fractures are missed during the initial medical visit. In particular, boys who present to a primary care or a general emergency department setting with an extremity fracture are at a particularly high risk for delayed diagnosis.
Ravichandiran
Nisanthini
N
Division of aPediatric Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
Schuh
Suzanne
S
Bejuk
Marta
M
Al-Harthy
Nesrin
N
Shouldice
Michelle
M
Au
Hosanna
H
Boutis
Kathy
K
D000058:Accidental Falls / Q000706:statistics & numerical data*; D000367:Age Factors; D002649:Child Abuse / Q000175:diagnosis* / Q000706:statistics & numerical data; D002675:Child, Preschool; D016001:Confidence Intervals; D057210:Delayed Diagnosis / Q000706:statistics & numerical data*; D003937:Diagnosis, Differential; D004636:Emergency Service, Hospital; D005260:Female; D050723:Fractures, Bone / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D015601:Injury Severity Score; D008297:Male; D019221:Mandatory Reporting; D020380:Needs Assessment; D016017:Odds Ratio; D009864:Ontario; D010808:Physical Examination / Q000379:methods; D011336:Probability; D012189:Retrospective Studies; D018570:Risk Assessment; D012737:Sex Factors