The question of suspected nonaccidental trauma as a possible cause of
injury for femoral shaft fractures in children is a troubling but common issue
facing orthopedic surgeons. The purpose of this study is to analyze femoral
shaft fractures at a major pediatric level I trauma center in a large
metropolitan area over a 5-year period to determine the incidence of suspected
nonaccidental trauma and the risk factors associated with that diagnosis. This
study is a retrospective review of all children younger than 5 years at a large
trauma center in a southwestern metropolitan area who presented with a femoral
shaft fracture. Patient charts were reviewed to determine demographics,
mechanism of injury, and fracture type. Referrals to social work and Child
Protective Services were also reviewed to determine an overall incidence of
suspected nonaccidental trauma.
Over the 5-year study period, 137 patients presented to our
institution with a femoral shaft fracture. Mean patient age at the time of
injury was 2.2 years (range, 1 month to 4 years). Overall, 43 patients with a
mean age of 1.8 years were determined to have injuries suspicious of
nonaccidental trauma and were referred to Child Protective Services, giving an
overall incidence of 31%. Age younger than 1 year was a highly significant risk
factor for suspected nonaccidental trauma. Of the 20 children younger than 1
year, 18 (90%) were referred to Child Protective Services, comprising 42% of
those children suspicious of nonaccidental trauma. The presence of either
Medicaid or no insurance was a highly statistically significant risk factor for
suspected nonaccidental trauma.
Femoral shaft fractures in children are one of the most common major
injuries that pediatric orthopedic surgeons manage. As orthopedists, we
commonly evaluate and treat femur fractures in different age groups, with
different fracture patterns and mechanisms of injury, and often with associated
injuries.1 Often, we are confronted with suspected nonaccidental
trauma as a possible cause of injury.
Nonaccidental trauma, or child abuse, continues to be a significant
cause of morbidity and mortality in children today.2-4 Second only
to burns and bruises, fractures are the second most common manifestation of
nonaccidental trauma. Certain fracture patterns are considered more suggestive
than others for nonaccidental trauma, including spiral humeral fractures,
metaphyseal corner fractures of the distal femur and tibia, and
others.5 Spiral fractures in general have been thought to have a
high likelihood of nonaccidental trauma because of the typical
“twisting” mechanism required to cause such a fracture. Therefore,
spiral femur fractures have also been associated with nonaccidental trauma, but
with less certainty than the other fractures discussed. Fractures of children
younger than 1 year are highly associated with nonaccidental trauma, because
infants do not have the mobility required to sustain accidental trauma with
sufficient energy to cause a fracture.
Several studies have been performed investigating the association of
nonaccidental trauma in femur fractures in children.6-9 These
studies have demonstrated that children younger than 1 year are at an increased
risk of nonaccidental trauma, and that no 1 particular fracture type is typical
of abuse. However, these previous studies have several limitations. Some of
these series have relatively small numbers with limited power to detect
accurately a trend with a relatively small magnitude, like the incidence of
nonaccidental trauma.7 Also, many of the previous reports had their
data derived from the late 1990s; the magnitude and characterizations of
nonaccidental trauma may be different in 2009 in the United
States.7-9 Finally, some studies do not distinguish between femoral
metaphyseal fractures (like corner fractures, which have a relatively high rate
of nonaccidental trauma) and femoral shaft fractures, which may have a much
lower incidence of abuse.6,7
The purpose of this study is to retrospectively analyze a large series
of femoral shaft fractures at a major pediatric level I trauma center in a
large southwestern metropolitan service area over a recent 5-year period.
Specifically, this study will determine the incidence of nonaccidental trauma
in femoral shaft fractures in children and will determine the characterizations
of that diagnosis by age, mechanism of injury, and fracture type.
Materials and Methods
All patients who presented with a femoral shaft fracture treated at
our institution, a high-volume, metropolitan level-I trauma center, from 2003
to 2008 were identified. The hospital’s Institutional Review Board
reviewed and approved the study. The patients were identified by a search of
the hospital’s ICD9 and discharge diagnoses. Patients with pathological
fractures (eg, osteogenesis imperfecta, fractures associated with osteomyelitis
or bone tumors) were excluded from the analysis. Patients with proximal femur
fractures (femoral neck, intertrochanteric, or subtrochanteric fractures) or
distal femur fractures (including metaphyseal distal femur fractures, which are
not frequently the result of abuse) were also excluded.
Data collected included patient age, sex, race/ethnicity, social
history, insurance type, fracture type, mechanism of injury, relevant
witnesses, associated injuries, treatment type, fixation type, complications,
reoperations, length of stay, forensic evaluation, and Child Protective
At our institution, if any physician has a suspicion of nonaccidental
trauma, a formal consult to the forensic team is instituted. This involves a
team comprising a physician, a nurse practitioner with special expertise in
nonaccidental trauma, and a social worker. Child Protective Services referral
may be made directly by the attending pediatric orthopedic surgeon or by the
The ultimate, legal determination of whether the child’s injuries
were sustained by nonaccidental trauma or by accidental trauma is ultimately
determined by Child Protective Services. The final decision by Child Protective
Services is protected data and usually not available in an analysis such as
this. The responsibility of the pediatric orthopedic surgeon (in terms of the
determination of whether a given injury is nonaccidental trauma) usually ends
after referral of the case to Child Protective Services. Therefore, we used
Child Protective Services referral as our primary endpoint. If Child Protective
Services immediately dismissed the case as accidental trauma during the index
hospitalization of the child, that case was excluded as a case of nonaccidental
Groups of fractures that occurred by nonaccidental trauma and by
accidental trauma were then compared on the basis of age, mechanism of injury,
fracture type, insurance status, and presence of associated injuries.
Statistical comparisons were made by the use of chi-squared analysis, with a
P value of .05 used to determine statistical significance.
The study identified 137 patients with femoral shaft fractures in
patients aged 5 years and younger during the time period of interest
(2003-2008). Mean patient age was 2±2 years (range, 1 month to
4±11 years). One hundred boys (73%) and 37 girls (27%) were identified.
Twenty patients were aged 1 year or younger (14%); the majority of fractures
occurred in children older than 1 year (86%).
Seventy-one fractures were midshaft spiral fractures (52%), 42 were
short oblique fractures (31%), 16 were transverse fractures (12%), and 8 were
comminuted fractures (6%). The mechanism of injury was a fall in 90 patients
(66%), twisting injury during play in 17 (12%), trampoline in 4 (3%), motor
vehicle accident in 4 (3%), and unknown in 22 (16%).
Eighteen patients (13%) of the 137 presented with associated injuries.
The types of injuries varied greatly, from small lacerations and abrasions to
other fractures, including skull fractures. Sixty-eight patients (49%) were on
Medicaid insurance plans, 58 (42%) were on commercial insurance plans, and 11
had no insurance (8%).
Of the 137 patients, 66 (48%) were referred to the forensics team by
the attending pediatric orthopedic surgeon. Of those 66, forty-three (65%) were
felt by forensics and/or the attending pediatric surgeon to be suspicious of
nonaccidental trauma, and a Child Protective Services referral was made.
Therefore, the overall rate of suspected nonaccidental trauma in this series
Eighteen of the 43 patients (42%) referred to Child Protective
Services were younger than 1 year. Eighteen of the 20 patients in the overall
series younger than 1 year were referred to Child Protective Services (90%).
Age was a highly significant risk factor for suspected nonaccidental trauma
(P<.0001). However, 25 additional patients older than 1 year were
felt to be suspicious for nonaccidental trauma, requiring a Child Protective
Services referral and investigation, with a risk factor of 21% (Figure 1).
|Figure 1: Effect of age on Child
Protective Services (CPS) referral for femoral shaft fracture. Abbreviation:
yo, year old.
Of those patients referred to Child Protective Services, 26 (60%) had
spiral fractures, 12 (28%) had oblique fractures, 3 (7%) had transverse
fractures, and 2 (5%) were comminuted. Fracture type was not a statistically
significant risk factor for suspected nonaccidental trauma (P=.56)
(Figure 2). Of those patients referred to Child Protective Services, the
mechanism of injury was fall in 22 patients (51%), twisting injury during play
in 3 (7%), motor vehicle accident in 1 (2%), and unknown in 17 (40%). An
unknown mechanism of injury was a highly significant risk factor for suspected
nonaccidental trauma (P<.0001) (Figure 3).
|Figure 2: Effect of fracture
type on Child Protective Services (CPS) referral. Abbreviation: NS, not
|Figure 3: Effect of mechanism of
injury (MOI) on Child Protective Services (CPS) referral.
Of the 18 patients with associated injuries, a forensics consult was
placed in 12 (67%). Child Protective Services referral was made in 9 cases
(50%). Of the 43 patients referred to Child Protective Services, 9 (21%) had
associated injuries. The presence of an associated injury was not a significant
risk factor for suspected nonaccidental trauma (P=.186).
Twenty-eight of the 43 children referred to Child Protective Services
were on Medicaid insurance plans (65%), 10 were on commercial plans (23%), and
5 had no insurance (12%). The presence of either Medicaid or no insurance was a
highly statistically significant risk factor for suspected nonaccidental trauma
(P=.008) (Figure 4).
|Figure 4: Effect of insurance
type on Child Protective Services (CPS) referral.
Femoral shaft fractures in children are a common injury treated by
pediatric orthopedic surgeons. Determining which of those patients is a
possible victim of abuse requires careful analysis of the patient’s
history, physical examination, and radiographs.5,10 Unfortunately,
the incidence of nonaccidental trauma in the pediatric population remains high
and is a significant problem facing our society.2-4 This study
retrospectively analyzed a large series of femoral shaft fractures at a major
pediatric level I trauma center in a large southwestern metropolitan service
area over a recent 5-year period.
Several studies investigate the association of nonaccidental trauma in
femur fractures in children. Hui et al6 found an incidence of
nonaccidental trauma in 127 femur fractures in children younger than 3 years
over an 11-year period to be 11%. Rex and Kay7 reported on a case
series of 33 femur fractures in children occurring from nonaccidental trauma
and compared that to a group of children with accidental femur fractures; 92%
of the fractures from nonaccidental trauma were in children younger than 1
year. Scherl et al8 found that in a cohort of >200 pediatric
femoral shaft fractures, other fracture types were just as prevalent in
nonaccidental trauma as the spiral fracture. Finally, Schwend et al9
reported that unless the child was younger than 1 year or there were other
signs suggestive of nonaccidental trauma, the likelihood of abuse was lower
than previously reported.
Many findings of the current study are similar to those previously
reported. In this study, the most highly significant risk factor for suspected
nonaccidental trauma was age younger than 1 year. That finding corroborates the
findings of many other studies.6,7,11 This study also supports the
findings of Scherl et al,8 in that fracture type was not a
significant risk factor for suspected nonaccidental trauma. Despite dogma, the
spiral femur fracture in children is not more highly associated with
nonaccidental trauma than any other fracture type.
However, this study also demonstrates findings that were not
previously reported. The presence of associated injuries (eg, cuts, bruises,
abrasions, other fractures) has long been thought to be a significant risk
factor for suspected nonaccidental trauma. This heightened awareness makes
clinical sense; however, the data in this study showed that the presence of an
associated injury was not a statistically significant risk factor for suspected
nonaccidental trauma, although the P value suggests that there may be a
positive trend and may be significant with a higher powered study. The lack of
a specific mechanism of injury was a significant risk factor for suspected
nonaccidental trauma, accounting for 40% of the cases referred to Child
It has been traditionally thought that child abuse crosses all
socioeconomic boundaries, and data exist to support that.2-5
However, the current study shows that if the patient was on Medicaid or had no
insurance, the femur fracture had a statistically higher chance of being the
result of nonaccidental trauma, compared to those patients with commercial
We used Child Protective Services referral as our primary endpoint for
several reasons. First, the final determination of whether a child is a victim
of nonaccidental trauma is many times not clearly delineated, even with a
thorough Child Protective Services evaluation. Second, many of the Child
Protective Services findings and the findings of subsequent legal proceedings
are not readily available to the public, even to the medical team taking care
of the child. Finally, we felt that the crucial responsibility of the
orthopedic surgeon in the determination of suspected nonaccidental trauma was
the referral to Child Protective Services. After that referral was made, the
medical–legal burden of the pediatric orthopedic surgeon is completed.
Almost of all of the children younger than 1 year who presented to our
institution with a femoral shaft fracture were referred to Child Protective
Services (90%). That is much higher than in previous studies,9 which
gave an overall incidence of nonaccidental trauma of 43% in children younger
than 1 year. We attribute our higher referral rate to our institution’s
adoption of the vigilance of suspicion of nonaccidental trauma suggested by
previous studies.6,8 Although most of our referrals were children
younger than 1 year, 25 patients older than 1 year (21%) were felt to be at
significant risk of nonaccidental trauma and warranted a Child Protective
Services referral. We suggest that vigilance and suspicion remain high despite
the age, and that nonaccidental trauma can occur in children older than 1
The association of lower insurance status and the risk factor for
nonaccidental trauma raises the question of the impact of socioeconomic status
and child abuse. While it is well known that child abuse can occur across all
levels of socioeconomic status, this study suggests that those children in
households with no insurance or government-subsidized insurance are at
increased risk for abuse. Other socioeconomic factors such as race, family
makeup (presence of the mother, father, or extended family members), and mean
annual income levels could also be investigated to determine their effects on
nonaccidental trauma. We chose insurance status as an independent variable to
minimize potential biases and prejudices that may come from other socioeconomic
The development and maturation of the forensics team and process at
our institution has greatly improved our ability to make proper referrals to
Child Protective Services and to improve the care of these children.
A femur fracture occurring in a patient younger than 1 year is a
significant risk factor for suspected nonaccidental trauma. The patient who is
uninsured or has Medicaid insurance also has a higher risk of being the victim
of nonaccidental trauma. However, the pediatric orthopedic surgeon should
always carefully examine each patient as a possible victim of nonaccidental
trauma and make referrals to Child Protective Services as necessary.
- Flynn JM, Schwend RM. Management of pediatric femoral shaft
fractures. J Amer Acad Orthop Surg. 2004; 12(5):347-359.
- Sedlak A, Broadhurst DD, eds. The Third National Incidence
Study of Child Abuse and Neglect: Final Report. Washington, DC: US
Department of Health and Human Services; 1996.
- US Department of Health and Human Services, National Center on
Child Abuse and Neglect. Child Maltreatment 1995: Reports From the States to
the National Child Abuse and Neglect Data System. Washington, DC: US
Government Printing Office; 1997.
- Lung CT, Daro D, eds. Current Trends in Child Abuse Reporting
and Fatalities: The Results of the 1995 Annual Fifty State Survey. Chicago,
IL: National Committee to Prevent Child Abuse; 1996.
- Kocher MS, Kasser JR. Orthopaedic aspects of child abuse. J Am
Acad Orthop Surg. 2000; 8(1):10-20.
- Hui C, Joughin E, Goldstein S, et al. Femoral fractures in children
younger than three years: the role of nonaccidental injury. J Pediatr
Orthop. 2008; 28(3):297-302.
- Rex C, Kay PR. Features of femoral fractures in nonaccidental
injury. J Pediatr Orthop. 2000; 20(3):411-413.
- Scherl SA, Miller L, Lively N, Russinoff S, Sullivan CM, Tornetta P
III. Accidental and nonaccidental femur fractures in children. Clin Orthop
Relat Res. 2000; (376):96-105.
- Schwend RM, Werth C, Johnston A. Femur shaft fractures in toddlers
and young children: rarely from child abuse. J Pediatr Orthop. 2000;
- Akbarnia BA, Akbarnia NO. The role of the orthopedist in child
abuse and neglect. Orthop Clin North Am. 1976; 7(3):733-742.
- Arkader A, Friedman JE, Warner WC Jr, Wells L. Complete distal
femoral metaphyseal fractures: a harbinger of child abuse before walking age.
J Pediatr Orthop. 2007; 27(7):751-753.
Drs Shrader and Segal and Mr Bernat are from the Division of Pediatric
Orthopedic Surgery, Phoenix Children’s Hospital, Phoenix, Arizona.
Drs Shrader and Segal and Mr Bernat have no relevant financial
relationships to disclose.
Correspondence should be addressed to: M. Wade Shrader, MD, Division of
Pediatric Orthopedic Surgery, Phoenix Children’s Hospital, 1919 E Thomas
Rd, Phoenix, AZ 85016 (firstname.lastname@example.org).