O2125: Common Misperceptions of Child Abuse in Toddler Femur Fractures

Background: Current AAOS guidelines recommend that all children younger than thirty-six months with a femur fracture be evaluated for child abuse. However, the chance for abuse in walking-age children is highly unlikely at less than 20%. The purpose of this study is to identify how a patient’s age and femur fracture morphology impact the likelihood that providers assess a fracture as non-accidental and their decision to pursue further investigation of possible child abuse.

Methods: This was a questionnaire study completed by clinicians from multiple specialties. There were 5 subgroup populations (6, 12, 18, 24, 35 months old) combined with 3 femur fracture types including oblique diaphyseal, spiral diaphyseal, and corner metaphyseal fracture (CML). For each age group, the same radiograph was presented and described as a corner fracture in one scenario and CML in another. Cases were also described as an oblique in one scenario and spiral diaphyseal fracture in another. Participants then assessed the percent likelihood each case represented non-accidental trauma utilizing a Likert scale from 1 to 5. Participants also rated how likely they were to take steps to pursue further investigation of child abuse.

Results: From 100 survey responses, 75% were fully completed and analyzed. Mean likelihood of abuse rating by fracture type in patients 18-35 months of age was 3.8, corresponding to 61-80% likelihood of abuse. Mean likelihood for further investigation of child abuse in patients 18-35 months of age was 3.7, corresponding to 61-80% likelihood to further investigate. Changing CML and corner descriptions significantly altered responses for patients 6, 12, and 35 months old. Similarly, changing oblique and spiral descriptions significantly changed responses in patients 12 and 24 months old. The strongest predictors of perceived high likelihood of abuse were respondent specialty, with emergency medicine (p < 0.001) and advanced practice providers (p=0.006) having the highest likelihood ratings. Results can be found in Table 1.

Conclusion: The AAOS guideline that recommends evaluating all children up to 36 months of age with a femur fracture for child abuse is opinion based rather than evidence based. The current study demonstrates that many physicians and advanced practice providers would report a pediatric femur fracture based on opinion rather than evidence. Accurate reporting of child abuse based on evidence should be the goal since overreporting may exhaust hospital and community resources in evaluating toddler femur fractures for abuse and cause unnecessary stress for patients and families.