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Humerus fractures in the pediatric population: an algorithm to identify abuse

Child abuse is a serious problem affecting the pediatric population, which has tremendous medical and social implications. There exists no gold standard test to diagnose child abuse, and as a result, clinicians are often in a difficult position of both protecting the child adequately, and respecting the rights and privacy of families. Upper extremity fractures are also common injuries seen in the emergency room, and a need exists to differentiate accidental from nonaccidental etiologies in young children. The purpose of this study was to produce an algorithm-based on statistical analysis that would allow clinicians to differentiate between humerus fractures stemming from abuse versus accidental trauma. We hypothesized that accidental humerus fractures in pediatric patients under the age of 4 years can be accurately distinguished from child abuse using a combination of history, physical exam findings, radiographic findings, and age. We searched our institutions Suspected Child Abuse and Neglect and trauma databases for nearly a decade. We identified 36 (representing 39 humerus fractures) patients in whom the etiology of their humerus fracture was abuse, and compared that group with 95 patients (representing 95 humerus fractures) in whom accidental trauma was the etiology. Univariate and multivariate statistical analysis techniques were applied to determine factors important in the diagnosis of child abuse given a humerus fracture. Univariate analysis found that location of fracture, polytrauma, age, prior injury, and history were factors that are important in the diagnosis of child abuse. Our multivariate analysis found that age above 18 months, physical and/or radiographic evidence of prior injury, and suspicious history were found in greater frequency in the group of patients experiencing abusive humerus fractures. In conclusion, based on our statistical analysis and earlier studies we developed an algorithm that clinicians can use to guide judgment and refer to social services when encountered with a young child presenting to the emergency room with a humerus fracture.