2025 Scholars' Research Symposium Abstract: The Relationship Between Bony Fractures and Child Abuse in Rural Pediatric Population.

Abstract

Introduction: Determining if injuries are the result of abuse in the pediatric population continues to be an arduous task for medical providers. In pediatric patients who are not yet mobile or verbal, diagnosing abuse can be even more difficult as histories must be taken from someone other than the patient, who may potentially be the abuser. Rates of child abuse also vary widely by demographics, including location. Rural areas have higher risk factors for child physical abuse, including higher rates of childhood poverty. This study aimed to identify injury trends and demographic populations of physical child abuse related to fractures in a rural Midwest pediatric population and compare them to national statistics.

Methods: This study utilized a retrospective chart review of Sanford Health Enterprise patients less than 12 months of age with ICD-10 fracture diagnoses between 2017 and 2021. An initial chart review was performed to identify mechanism of injury, demographics, and other medical information. A second chart review was performed, by a child abuse pediatrician, for inter-rater reliability, as well as context for perpetrator information, location of abuse, and child abuse specialist findings. This child abuse pediatrician then categorized each patient's case as "Consistent with Abuse", "Concern for Abuse/Indeterminant", or "Accidental/Medical". Wilcoxon rank-sum and Fisher's exact tests were conducted to identify statistically significant differences among patients in each category.

Results: 107 patients were included in the study. Patients with injuries consistent with abuse were younger than those with injuries deemed indeterminate or concerning for abuse, as well as those with accidental or medical injuries (p =0.008). Injuries such as skull, facial, and rib fractures, injuries to the chest, and bruising were more strongly associated with abuse, while upper and lower extremity injuries were not. Over half of the cases consistent with abuse involved patients with undocumented or inconsistent explanations for their injuries. Compared to femur fractures being the most common bone fracture secondary to child abuse in national studies, rib fractures and chest injuries were more common in this rural Midwest pediatric sample. Additionally, the presence of other fractures identified through skeletal surveys further increased the likelihood of abuse.

Conclusions: This study highlights the correlation between injury patterns of physically abused pediatric patients in the rural population. Younger patients with bone fractures were more likely to be abused compared to those with accidental injuries. Inconsistent or undocumented mechanisms of injury were also more common in abuse cases. These findings suggest younger patients with bone fractures or an unknown mechanism should be extensively evaluated for child abuse. Skeletal surveys remain paramount to investigating abuse, with many additional bone fractures secondary to abuse being identified with this method. These findings underscore the importance of thorough documentation, examination, and use of skeletal surveys in patients less than twelve months old with bone fractures.