Fracture patterns in non-accidentally injured children at the Red Cross Children’s Hospital

Abstract

Background: Unexplained fractures in infants and children often suggest abuse. The fracture patterns with high specificity for abuse are well documented, however, in practice these patterns occur infrequently and abused children may present with a wide spectrum of bony injuries. The Child Accident Prevention Foundation of South Africa (CAPFSA) keeps a database of children treated at the Red Cross War Memorial Children’s Hospital (RXH) in Cape Town.
Methods: The medical records of all children admitted between January 1991 and October 2005 were reviewed and children with fractures resulting from non-accidental injury (NAI) were included in the study.
Results: During the 14-year study period, 99586 trauma patients were treated at RXH, of which 1037 (1.04%) were diagnosed with non-accidental injury. The majority was male (64%). An the average age was 44.8 months. Of the 1037 patients diagnosed with NAI, 121 (11.7%) sustained a total of 149 fractures; 21 (17.3%) with multiple fractures (16 had 2 fractures, 3 had 3 fractures and 2 had 4 fractures). The head and neck was the most frequently fractured anatomical area (53%), followed by the upper limb (24%) and lower limb (18%). Only 7 fractures of the trunk were seen. Children sustaining fractures of the head and neck were significantly younger than those sustaining fractures to other areas.
Discussion: Although the established consensus on fracture patterns in NAI is that long bone fractures are the most frequently experienced in clinical practice, the principal finding of our study was that skull fractures were considerably more common; nearly 40% of all fractures were skull fractures. Skull fractures were associated with violent injury; approximately one-third were reported to have been inflicted with an implement/weapon and one-quarter of these children had multiple fractures at the time of presentation. This underlines the importance of local studies, as socio-cultural issues underpin many of the aetiological factors related to disease burden in general, and to child abuse in particular.