How well can doctors diagnose child abuse from bone fractures?

Originally published in MedPage Today

by Chris Emery, MedPage Today Contributing Writer

Physicians often misdiagnose bone fractures caused by child abuse as accidental breaks, particularly if the child is male and the doctor is not a pediatrician, a new study found.

Of children who suffered fractures from abuse, about 20% had at least one previous medical visit during which a doctor missed signs of the problem (95% CI 15.8 to 26.0), according to a report published online Nov. 30 in Pediatrics. It took a median of eight days after the initial visit before doctors correctly assessed abuse during a subsequent examination.

Doctors were most likely to misdiagnose abusive fractures if the patients were boys, had breaks in the limbs, or were seen in a primary care setting or general emergency room, as opposed to a pediatric emergency department.

“This study is the first to report the frequency of delayed recognition of abusive fractures in children,” Kathy Boutis, MD, MSc, of the Hospital for Sick Children, University of Toronto, and colleagues wrote. “One-fifth of children with abusive fractures were missed at initial physician visits, which is comparable to that reported for other types of abuse; however, we do not know how many cases of abusive fractures are never detected.”

While fractures are common signs of child abuse and repeat injuries occur in 35% of child abuse cases, previous research suggested that doctors have difficulty distinguishing breaks caused by accidents from those resulting from abuse — and thus miss a chance to prevent further abuse.

However, the frequency at which cases of abuse are overlooked was unknown.

The authors assessed 258 cases of children younger than 3 years treated for abusive fractures at Toronto Hospital for Sick Children between January 1993 and December 2007. The children had seen physicians previously for treatment of fractures. Of the children, 54 had a least one previous visit with a physician at which abuse was missed, the study found.

Abuse-related fractures were nearly twice as likely to be missed in boys as in girls. “Although the reason for this is unclear, injuries in general occur more often in boys, which may bias a clinician in assuming that the cause of a fracture is accidental,” the authors wrote.

Of the 145 children with breaks to an extremity, 28% (95% CI 20.8 to 35.8) were cases of abuse that were overlooked. About a third of the cases of abuse that were missed on the initial visit were the result of physicians not diagnosing fractures from radiographs.

“This study suggests that front-line physicians should strongly consider consulting a radiologist when the presence of a fracture may lead to increased suspicion of abuse,” the authors wrote.

They also suggested that physicians carefully check for other risk factors of abuse in children with fractures and that they err on the side of performing skeletal surveys for children who are at higher risk.

They cautioned that the study was retrospective, and that some cases of abuse may have been overlooked by the researchers because they were never referred to the child protection team at the hospital.

On the other hand, complex cases may not have been referred to the child abuse team, which may have elevated the estimate of the percentage of abuse cases that are overlooked on a child’s initial physician visit for a fracture.

“However,” the authors wrote, “child abuse is under-recognized, and there is also the possibility that we are underestimating the proportion of cases missed.”

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