Tibial fractures in very young children and child abuse

Report By: Rob Williams - Specialist Registrar
Search checked by N Hardcastle - Senior House Officer, Hope Hospital, Salford
Institution: Manchester Royal Infirmary
Date Submitted: 21st April 2006
Date Completed: 24th May 2006
Last Modified: 21st April 2006
Status: Green (complete)

Three Part Question

In [very young children who present with tibial fractures] what are [the relative chances] of [accidental and non-accidental injury]?

Clinical Scenario

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.

Search Strategy

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

Search Outcome

44 papers were found of which 3 were of some relevance to the question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Mellick LB and Reesor K, 1990, USA	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, 2002, UK	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, 2005, USA	26 children aged 18 months or less with tibial fractures	Retrospective survey	Abuse	25 (96%)	Small number of cases from a large survey

Comment(s)

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

References

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.