Three Part Question
In [very young children who present with tibial fractures] what are [the relative chances] of [accidental and non-accidental injury]?
An 18 month old child attends the department with a limp. You question the mother of the child who explains that the child has fallen down three stairs at home. X-ray reveals a transverse tibial fracture. Further inquiry is unrewarding, and you wonder whether the prescence of the fracture alone is sufficient to support a diagnosis of non-accidental injury.
EMBASE <1980 to 2006 Week 12
Ovid MEDLINE(R) <1966 to March Week 3 2006
The Cochrane Library 2006, Issue 1
Embase/Medline:(exp battered child syndrome OR battered child syndrome.mp OR child abuse OR non-accidental injury.mp OR non-accidental trauma.mp) AND (exp tibial fractures OR transverse tibial fracture$.mp OR spiral tibial fracture$.mp) LIMIT to human AND English.
Cochrane:[Child abuse [MeSH] ] AND [tibial fractures [MeSH]] – 0 results
44 papers were found of which 3 were of some relevance to the question
|Author, date and country
||Study type (level of evidence)
|Mellick LB and Reesor K,|
|10 children aged less than 4 years with isolated spiral tibial fractures||Case series||Number of non accidental injuries||1 (10%)||Small series subject to inclusion bias|
|Banaszkiewicz PA et al,|
|5 children aged less than I year with tibial fractures||Retrospective survey||Definite abuse||1 (20%)||Very small number of tibial fractures in the study
Retrospective assessment of abuse risk|
|Likely abuse||1 (20%)|
|Suspicious of abuse||1 (20%)|
|Coffey C et al,|
|26 children aged 18 months or less with tibial fractures||Retrospective survey||Abuse||25 (96%)||Small number of cases from a large survey|
The numbers of children with the target condition (tibial fracture) in the case series is small. However in the cases found there seems to be a clear link between tibial fractures in very young children (aged 18 months or less) and non-accidental injury.
Clinical Bottom Line
Very young children with tibial fractures should be closely assessed for non-accidental injury
- Mellick LB. Reesor K. Spiral tibial fractures of children: a commonly accidental spiral long bone fracture. American Journal of Emergency Medicine. 8(3):234-7, 1990 May.
- Banaszkiewicz PA. Scotland TR. Myerscough EJ. Fractures in children younger than age 1 year: Importance of collaboration with child protection services. Journal of Pediatric Orthopedics. Vol. 22(6)(pp 740-744), 2002
- Coffey C. Haley K. Hayes J. Groner JI. The risk of child abuse in infants and toddlers with lower extremity injuries. Journal of Pediatric Surgery. Vol. 40(1)(pp 120-123), 2005.