246 - Caregiver reported injury setting and presence of non-caregiver witnesses among young children with femur fractures

Publication Number: 2237.246

Stephanie M. Ruest, Hasbro Children's Hospital at Rhode Island Hospital, Foxboro, MA, United States; Emely Arenas Lemus, Hasbro Children's Hospital at Rhode Island Hospital, Westport, MA, United States; William Rudman, The University of Texas at Austin, Austin, TX, United States; Susan Duffy, Hasbro Children's Hospital at Rhode Island Hospital, Providence, RI, United States; Amy P. Goldberg, The Warren Alpert Medical School of Brown University, Providence, RI, United States

Background: Some literature has recommended that children < 18 months without an "independently verified" accidental mechanism for a femur fracture should undergo routine abuse evaluation.

Objective: We aim to characterize the setting where femur fractures occur and presence of a non-caregiver adult witness to corroborate the injury mechanism among children ≤5 years old.

Design/Methods: This is a sub-analysis of a retrospective study of 4,285 children ≤5 years seen with fractures in a pediatric emergency department between March 2015 and April 2023. Acute femur fracture encounters were identified by ICD9/10 codes and confirmed by chart review. Patient age, caregiver-reported injury setting (i.e., public, private, not documented, no trauma history) and presence of a non-caregiver adult witness to corroborate the injury mechanism were abstracted. Descriptive statistics are reported.

Results: We identified 185 unique acute femur fracture encounters, with a mean patient age of 28.8 months (SD 19.2). A non-caregiver adult witness was documented in 11.4% of all encounters (N=21). Six children < 6 months (33.3%) had no reported trauma, 2 (11.1%) had an undocumented setting, and 10 (50%) were injured in private settings. Five children 6->36 months (1.8%) had no reported trauma; 14 (8.4%) had undocumented settings. Ninety-one children 6- < 36 months (83.5%) and 36 (62.1%) children ≥36 months sustained injuries in private settings. Nine children 6- < 36 months (8.3%) were injured in public, whereas 12 children ≥36 months (20.7%) were injured in public.

Conclusion(s): Femur fractures in this study population uncommonly occurred in public settings or in the presence of non-caregiver witnesses across all age groups. While the presence of an injury sustained in public and/or with independent witness corroboration supports an accidental cause, the utility of discerning risk of abuse versus accident in their absence is limited. This is the first study to characterize the frequency with which young children sustain femur fractures in public settings and in the presence of a non-caregiver adult witness.

Figure 1. Proportion of encounters with adult non-caregiver witnesses, by age group
Overall, 11.4% of femur fractures (N=21) had an adult non-caregiver witness to corroborate the injury mechanism.

Figure 2. Injury settings, by age group
Private locations include: house or private yard, private daycare, hotel. Public locations include: school, park, water park, trampoline park, store, casino, public orchard, motor vehicle crash, pedestrian struck on street.