title: Identifying non-accidental fractures in children aged <2 years.
abstract: OBJECTIVE
  Fractures are the second most common presentation of child abuse following soft-tissue bruising and burns. It is often difficult to determine potential abuse in a child presenting with a non-rib fracture(s) and without soft-tissue injuries.
  
  
  METHODS
  One hundred and fifteen consecutive patients aged ≤2 years who presented with a fracture between January 2010 and June 2012 to our emergency department (ED) or pediatric fracture clinic were retrospectively analyzed. Statistical analyses were carried out for non-accidental fractures based on age (<1 year vs 1-2 years), location of presentation (ED vs pediatric fracture clinic), type of long bone fracture, number of fractures, and patient demographics.
  
  
  RESULTS
  Fractures in 19 of 115 (17 %) patients were reported as non-accidental trauma (NAT). Eighty (70 %) of the 115 patients first reported to the ED. Thirty-two percent of fractures in children aged <1 year and 5 % of fractures in children aged 1-2 years were reported as NAT (p < 0.001). Sixteen of 19 (84 %) patients reported for abuse had multiple fractures; 15 of these patients were aged <1 year. Eight of 11 (73 %) reported femoral fractures were transverse fractures. Corner fractures (12) only occurred in children aged <1 year and never occurred in isolation; all of them were reported as NAT. Four of 60 patients (7 %) with commercial insurance and 15 of 55 patients (28 %) with Medicaid were reported as NAT.
  
  
  CONCLUSIONS
  Age less than 1 year, multiple fractures, corner fractures, transverse fractures, and covered by Medicaid were the most common factors associated with reporting of NAT.
authors.affiliation: Department of Family Medicine, Lancaster General Health, Lancaster, PA, USA.
authors.forename: Laura A
authors.initials: LA
authors.lastname: Leaman
authors.affiliation: Department of Orthopaedics and Rehabilitation, The Pennsylvania State University College of Medicine, Hershey, PA, USA.
authors.forename: William L
authors.initials: WL
authors.lastname: Hennrikus
authors.affiliation: Department of Orthopaedics and Rehabilitation, The Pennsylvania State University College of Medicine, Hershey, PA, USA. jbresnahan@hmc.psu.edu.|Pennsylvania State University College of Medicine, 500 University Dr., Hershey, PA, United States. jbresnahan@hmc.psu.edu.
authors.forename: James J
authors.identifier: http://orcid.org/0000-0002-9712-4629
authors.initials: JJ
authors.lastname: Bresnahan
keywords: Child abuse; Fracture; NAT; Non-accidental; Trauma