242 - Analyzing Injury Narratives to Distinguish Abuse from Accidental Spiral Humerus Fractures in Young Children

Publication Number: 2233.242

Kim Kaczor, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Karen L. Bertocci, University of Louisville, Louisville, KY, United States; Gina Bertocci, University of Louisville, Louisville, KY, United States; Stephanie Ettinger de Cuba, Boston University School of Public Health, Boston, MA, United States; Lisa C. Allee, Boston Medical Center, Community Violence Response Team (CVRT), Boston, MA, United States; Kristine Fortin, chil, Philadelphia, PA, United States; Mary clyde Pierce, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States

Background: Children aged 0-5 years account for about 20% of fracture (fx)-related Emergency Department (ED) visits. Distinguishing accidental from abuse-related fractures remains challenging, with risks of both over- and under-diagnosis. Spiral fractures, once thought highly indicative of abuse are now recognized as less specific. Fracture characteristics alone cannot determine cause, therefore, a more nuanced understanding of contextual factors such as injury history and care-seeking patterns may improve assessment of injury plausibility.

Objective: To analyze injury history narratives associated with humeral spiral fractures, including why and when children are brought for care and presence of additional injuries, and compare these characteristics between cases classified as abuse and accidents.

Design/Methods: We conducted a thematic analysis using a prospectively collected, multi-center dataset of children < 4 years with ≥1 long bone fracture (n=803). An independent medical expert panel (MEP) classified each case as abuse, accident, or indeterminate. All humeral spiral fractures with a MEP classification of abuse or accident (n=31) were included in this subanalysis. We reviewed descriptions of child and injury details from caregiver interviews, clinical notes, and imaging reports. Two researchers independently coded narratives using a priori and inductive codes and resolved discrepancies by discussion. Axial coding identified overarching themes, and descriptive statistics were calculated.

Results: Of 31 cases, 24 (77.4%) were classified as abuse, 7 (22.6%) as accident. All accident cases involved a single fracture (Table), had a clear injury history, and presented first to an ED or urgent care. Except for one, each accidental case had no additional injuries (Table). In contrast, 50% of abuse cases had other injuries (Table), 54% presented with nonspecific medical complaints rather than injury histories, and 25% first sought care from a primary provider. Time from injury or symptom recognition to care was documented for all accidents versus 75% of abuse cases. Time to care could not be determined for 25% due to absent, vague, or convoluted histories. Six of seven accidents were brought for care immediately, whereas among abuse cases, nine (of 18) presented 5-60 hours after the event or symptom recognition, and nine within 0-3 hours.

Conclusion(s): Differences in reasons for seeking care, timing of presentation, and presence and number of additional injuries distinguished abuse from accidental spiral humeral fractures in young children. These contextual features may aid clinicians in evaluating injury plausibility.

Other injuries identified in patients with spiral humerus fractures, by MEP classification (numbers are patient counts)