title: The incidence of fractures in children under the age of 24 months--in relation to non-accidental injury.
abstract: BACKGROUND
  Fractures in children are the second most common presentation of child abuse. In younger children, especially in those less than 18 months, fractures should be considered suspicious of a non-accidental injury (NAI). Risk factors associated for abuse are: age younger than 12 months, non-ambulatory status, delayed presentation, unknown or inconsistent history of mechanism of injury, and presence of any other injuries. Our objective was to identify the incidence of fractures in children below the age of 24 months who presented to our institution's Emergency Department (ED), and identify which cases should arouse suspicion around possible NAI.
  
  
  METHODS
  A 2 year retrospective analysis was carried out of our ED and hospital notes from 2007 to 2008, of all children under the age of 24 months who presented with a fracture of any description to the ED. The study looked at the patients age (months) and gender, the site and type of fracture, whether the patient was hospitalised or discharged from the ED, if any concern was reported or a child protection referral was made, and also the area of the city the child was from.
  
  
  RESULTS
  In 2007-2008 there was an incidence of 53 fractures per 10,000 children less than 2 years. The proportion increased with age with femur and skull fractures found in the youngest age category being associated with a referral to the child protection services. An unclear history regarding mechanism of injury was also noted in a high proportion of referrals. In 34% of patients the time interval was not recorded, a crucial risk factor in NAI.
  
  
  CONCLUSIONS
  Age is a strong determinant when accessing NAI and a non-ambulant child presenting with a femur or skull fracture should be regarded highly suspicious of NAI. The time interval between the injury and presentation to the ED must be recorded in all notes when assessing a child for NAI.
authors.affiliation: Southampton University Hospitals NHS Trust, MP 817, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, United Kingdom. ortho@soton.ac.uk
authors.forename: Nicholas M P
authors.initials: NM
authors.lastname: Clarke
authors.forename: Fenella R M
authors.initials: FR
authors.lastname: Shelton
authors.forename: Colm C
authors.initials: CC
authors.lastname: Taylor
authors.forename: Tajjali
authors.initials: T
authors.lastname: Khan
authors.forename: Senbaga
authors.initials: S
authors.lastname: Needhirajan
mesh_terms: D017677:Age Distribution; D002649:Child Abuse / Q000175:diagnosis / Q000706:statistics & numerical data*; D005260:Female; D005264:Femoral Fractures / Q000175:diagnosis / Q000453:epidemiology*; D019983:Guideline Adherence; D006801:Humans; D015994:Incidence; D007223:Infant; D007229:Infant Welfare; D007231:Infant, Newborn; D008297:Male; D008487:Medical History Taking; D009104:Multiple Trauma / Q000175:diagnosis / Q000453:epidemiology*; D012017:Referral and Consultation; D012189:Retrospective Studies; D018570:Risk Assessment; D017678:Sex Distribution; D012887:Skull Fractures / Q000175:diagnosis / Q000453:epidemiology*; D006113:United Kingdom