title: Transverse fractures of the femoral shaft are a better predictor of nonaccidental trauma in young children than spiral fractures are.
abstract: BACKGROUND
  Certain fracture configurations, especially spiral fractures, are often thought to be indicative of nonaccidental trauma in children. The purpose of this study was to determine whether femoral fracture morphology, as determined by an objective measurement (fracture ratio), was indicative of nonaccidental trauma in young children.
  
  
  METHODS
  Consecutive patients who were three years of age or younger and had a closed, isolated femoral shaft fracture treated at an urban pediatric level-I trauma center between 2005 and 2013 were identified. Anteroposterior and lateral fracture ratios (fracture length/bone diameter) were calculated for each patient by a fellowship-trained pediatric orthopaedic surgeon who was blinded to the patient's clinical history. The presence or absence of a Child Protective Services referral as well as institutional Child Assessment Program evaluations were reviewed. Nonaccidental trauma was deemed to be present, absent, or indeterminate by Child Protective Services or an on-site Child Assessment Program team. To further evaluate and quantify the likelihood of nonaccidental trauma, the criteria of the Modified Maltreatment Classification System were used.
  
  
  RESULTS
  Of 122 patients identified, ninety-five met the inclusion criteria for this study. Of these ninety-five, fifty-one (54%) had either a Child Protective Services or a Child Assessment Program consultation because of suspected nonaccidental trauma. Thirteen (25%) were found to have nonaccidental trauma as determined by Child Protective Services or the Child Assessment Program team and seven (14%) had indeterminate Child Protective Services or Child Assessment Program investigations. All thirteen patients with nonaccidental trauma, as well as the seven patients with an indeterminate Child Protective Services or Child Assessment Program investigation, had positive Modified Maltreatment Classification System scores for physical abuse. Patients who had nonaccidental trauma had significantly decreased mean anteroposterior fracture ratios compared with those who had confirmed accidental trauma (p < 0.0001).
  
  
  CONCLUSIONS
  The fracture ratio can be helpful to determine fracture morphology and can be used as part of the assessment of a child with suspected nonaccidental trauma. While not diagnostic, the presence of a transverse diaphyseal femoral fracture in a young child should raise the index of suspicion for nonaccidental trauma.
  
  
  METHODS
  Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee, 1211 Union Avenue, Suite 510, Memphis, TN 38104. E-mail address for J.R. Sawyer: jsawyer@campbellclinic.com.
authors.forename: Ryan
authors.initials: R
authors.lastname: Murphy
authors.affiliation: Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee, 1211 Union Avenue, Suite 510, Memphis, TN 38104. E-mail address for J.R. Sawyer: jsawyer@campbellclinic.com.
authors.forename: Derek M
authors.initials: DM
authors.lastname: Kelly
authors.affiliation: Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN 38103.
authors.forename: Alice
authors.initials: A
authors.lastname: Moisan
authors.affiliation: Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee, 1211 Union Avenue, Suite 510, Memphis, TN 38104. E-mail address for J.R. Sawyer: jsawyer@campbellclinic.com.
authors.forename: Norfleet B
authors.initials: NB
authors.lastname: Thompson
authors.affiliation: Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee, 1211 Union Avenue, Suite 510, Memphis, TN 38104. E-mail address for J.R. Sawyer: jsawyer@campbellclinic.com.
authors.forename: William C
authors.initials: WC
authors.lastname: Warner
authors.affiliation: Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee, 1211 Union Avenue, Suite 510, Memphis, TN 38104. E-mail address for J.R. Sawyer: jsawyer@campbellclinic.com.
authors.forename: James H
authors.initials: JH
authors.lastname: Beaty
authors.affiliation: Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee, 1211 Union Avenue, Suite 510, Memphis, TN 38104. E-mail address for J.R. Sawyer: jsawyer@campbellclinic.com.
authors.forename: Jeffrey R
authors.initials: JR
authors.lastname: Sawyer
mesh_terms: D002649:Child Abuse / Q000175:diagnosis*; D002675:Child, Preschool; D005260:Female; D005264:Femoral Fractures / Q000145:classification / Q000209:etiology*; D006801:Humans; D007223:Infant; D008297:Male; D016037:Single-Blind Method