Fractures in young children: are physicians in the emergency department and orthopedic clinics adequately screening for possible abuse?

OBJECTIVES

1) To determine whether physicians are sufficiently investigating the cause of fractures in children younger than 3 years and 2) to find out what influences physicians' quality of history taking and documentation necessary to rule out inflicted trauma.

DESIGN

Descriptive, retrospective chart review.

SETTING

Pediatric emergency department and orthopedic clinic of an urban teaching hospital.

SUBJECTS: Children younger than 3 years treated between January 1, 1995, and December 31, 1998, presenting with a fracture.

RESULTS

A total of 653 charts met entry criteria. Information that was significantly lacking in the recorded history included witness presence, history of previous injury, review of past medical record, other injury description, and whether the injury was consistent with the development of the child. It was not possible to rule out inflicted injury in 42% of the patients. Four groups emerged from the entire cohort: group 1, accidental trauma, which made up 63% of the entire group (n = 413); group 2, inflicted trauma, which made up 13% (n = 85); group 3, missed inflicted trauma, which made up 23% (n = 151); and group 4, missed accidental trauma, which made up 0.6% (n = 4). Younger age of the child, multiple fractures, need for hospital admission, and the examining physician being a pediatrician positively influenced physicians' propensity to accurately report inflicted trauma.

CONCLUSIONS

A large percentage of the charts reviewed contained inadequate documentation to explain the cause of fractures and thereby rule out inflicted trauma. Information in 23% of the charts reviewed aroused suspicion of inflicted trauma. There is a need to ensure that adequate information is obtained and documented in hospital records to rule out inflicted injury. This will require changes in the knowledge, skills, and attitudes of physicians. The use of forms, protocols, and periodic chart review will help to ensure compliance.