title: Missed opportunities to diagnose child physical abuse.
abstract: OBJECTIVE
  This study aimed to determine the incidence of missed opportunities to diagnose abuse in a cohort of children with healing abusive fractures and to identify patterns present during previous medical visits, which could lead to an earlier diagnosis of abuse.
  
  
  METHODS
  This is a retrospective descriptive study of a 7-year consecutive sample of children diagnosed with child abuse at a single children's hospital. Children who had a healing fracture diagnosed on skeletal survey and a diagnosis of child abuse were included. We further collected data for the medical visit that lead to the diagnosis of child abuse and any previous medical visits that the subjects had during the 6 months preceding the diagnosis of abuse. All previous visits were classified as either a potential missed opportunity to diagnose abuse or as an unrelated previous visit, and the differences were analyzed.
  
  
  RESULTS
  Median age at time of abuse diagnosis was 3.9 months. Forty-eight percent (37/77) of the subjects had at least 1 previous visit, and 33% (25/77) of those had at least 1 missed previous visit. Multiple missed previous visits for the same symptoms were recorded in 7 (25%) of these patients. The most common reason for presentation at missed previous visit was a physical examination sign suggestive of trauma (ie, bruising, swelling). Missed previous visits occurred across all care settings.
  
  
  CONCLUSIONS
  One-third of young children with healing abusive fractures had previous medical visits where the diagnosis of abuse was not recognized. These children most commonly had signs of trauma on physical examination at the previous visits.
authors.affiliation: From the Divisions of *Pediatric Emergency Medicine, and †Child Advocacy Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA.
authors.forename: Elizabeth L
authors.initials: EL
authors.lastname: Thorpe
authors.forename: Noel S
authors.initials: NS
authors.lastname: Zuckerbraun
authors.forename: Jennifer E
authors.initials: JE
authors.lastname: Wolford
authors.forename: Rachel P
authors.initials: RP
authors.lastname: Berger
mesh_terms: D002648:Child; D002649:Child Abuse / Q000175:diagnosis* / Q000706:statistics & numerical data*; D002675:Child, Preschool; D057210:Delayed Diagnosis / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D012189:Retrospective Studies