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Humeral fractures and non-accidental injury in children
  1. Robert Williams, Specialist Registrar,
  2. N Hardcastle, Senior House Officer
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; kevin.mackway-jonesman.ac.uk

    Abstract

    A short cut review was carried out to establish whether proximal humeral fractures in children are indicative of non-accidental injury. Altogether 44 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

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    Report by Robert Williams, Specialist RegistrarChecked by N Hardcastle, Senior House Officer

    Clinical scenario

    A 22 month old child attends the department and is reported not to be using her arm. You question the mother of the child who explains the child seems to have injured herself at nursery, although no one can corroborate the story. Radiography shows an undisplaced humeral fracture. Further inquiry is unrewarding, and you wonder whether the presence of the fracture alone is sufficient to support a diagnosis of non-accidental injury.

    Three part question

    In [children in whom non-accidental injury is suspected] what [is the specificity of] an [isolated proximal humeral fracture]?

    Search strategy

    Medline 1969–10/04 using the OVID interface. [Exp battered child syndrome OR battered child syndrome.mp OR exp child abuse OR non-accidental injury.mp OR NAI.mp] AND [exp humeral fractures OR {(exp fractures OR fracture$.mp OR exp fractures, closed OR exp fractures, open) AND (exp humerus OR humer$.mp)}].

    Search outcome

    Altogether 44 papers were found of which 42 did not address the question directly. The remaining two papers are shown in table 4.

    Table 4

    Comment(s)

    The detection and diagnosis of child abuse is difficult and requires a holistic approach. However, traditional teaching has suggested that certain injuries are pathognomic of abuse. These papers attempt to define the specificity for child abuse of various types of humeral fracture. However, both studies lack an adequate “gold standard” that abuse was the cause. It is possible that abused children may have been missed and also the converse could be true. Despite this, the reported incidence of abuse associated with these fractures seems high. In particular spiral or oblique fractures, in children under the age of 3 more often occur as a result of abuse.

    CLINICAL BOTTOM LINE

    Although not pathognomonic of child abuse, the presence of a humeral fracture in a young child should lead to further investigation of its cause.

    Report by Robert Williams, Specialist RegistrarChecked by N Hardcastle, Senior House Officer

    References

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