Management of limb fractures in children under 1 year of age in a dedicated paediatric emergency department

Abstract

Background: The recognition of possible non-accidental injury (NAI) in children is an area of ongoing concern for all emergency departments. Limb fractures in non-mobile children should alert clinicians to consider NAI and refer the child for further management. A study was undertaken of the management of such children in a paediatric emergency department (PED) to identify the age and sex of such infants, their mechanism of injury, documentation of developmental milestones, the type of fracture sustained, the number of previous attendances and evidence of referral for senior review and referral to the social services (where appropriate).

Method: The study was conducted in a large PED which currently sees over 30 000 children per year. A retrospective review was carried out of the notes of all children under 1 year of age presenting with a limb fracture over a 4.5-year period. Patients were identified by their discharge diagnosis on the computerised emergency department (ED) system.

Results: 20 497 children under the age of 1 year presented to the ED during the study period. 244 of these presented with limb injuries, of which 39 had fractures. Of these, 36 sets of notes were analysed; 14 of the children were referred for senior review, 10 of whom were thought to be possible NAI and were admitted for further management (median age 23.5 weeks (range 6–48)). This left 22 children under 1 year of age who were seen and managed solely by a PED senior house officer (median age 43 weeks (range 26–51)). In the opinion of the reviewing clinicians, six of these cases may have benefited from senior review.

Conclusion: Limb fractures in non-mobile children account for a small proportion of PED attendances. There needs to be increased awareness of the potential for NAI in this population. Documentation and understanding of developmental history must be emphasised to show that this has been considered in relation to NAI. Children under 1 year of age are particularly vulnerable and, when they present with a limb fracture, they must be discussed with a senior paediatrician. The changes made locally are discussed and a suggested flow chart provided for possible use in other departments.