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Complete distal femoral metaphyseal fractures: a harbinger of child abuse before walking age.

BACKGROUND: Next only to burns and bruises, fractures are the second most common sign of the physical form of child abuse. Although there is not a pathognomonic fracture pattern associated with child abuse, distal femur "corner" fractures are often considered a clue to diagnosis, particularly in children younger than 1 year old. We contend that complete metaphyseal fractures of the distal femur are a potential harbinger of child abuse in children before walking age.

METHODS: This was a retrospective study performed at 2 level 1 pediatric trauma centers. Query of a trauma database in a 10-year period yielded 29 children that sustained complete metaphyseal fractures of the distal femur. Medical charts and radiographs were reviewed. Data collection included age, sex, side, mechanism of injury, associated injuries, child protective services evaluation, and primary pediatrician notes.

RESULTS: Of the 29 fractures, 20 occurred in children 1 year old or younger (before walking age) and formed the final studied group. The average age for the 14 boys and 6 girls was 6 months 10 days (range, 5 days to 1 year). Ten cases (50%) were confirmed to be a result of child abuse, and another 5 cases (25%) were highly suspicious for abuse. In all, 15 of the 20 children (75%) with complete distal femoral metaphyseal fractures were potentially victims of child abuse.

CONCLUSIONS: Based on our results, we recommend that when evaluating children before walking age with a complete distal femur metaphyseal fracture, further inquiry for possible etiology of child abuse should be performed.

LEVEL OF EVIDENCE: Level IV--case series, diagnostic.

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