Differentiating abusive from accidental fractures


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This literature review provides a framework on how to decide, based on history and fracture morphology, whether a fracture is likely to result from an accident or abuse.[1] Fractures shown to be caused more frequently by abuse than by accidental injury include metaphyseal, posterior rib, scapular, sternal and pelvic fractures. The likelihood of abuse increases with more than one concurrent fracture: 18.5% of single fractures are caused by abuse compared with 55.1% of injuries with two fractures and 85.4% of injuries with three fractures. Multiple fractures at various stages of healing are obviously highly suggestive of abuse. The age of the child can be helpful as 80% of abusive fractures occurred in children <18 months old.

This paper provides a particularly useful framework to assist in determining injury plausibility called the ‘HITS’ of injury plausibility (Table). The questions can be easily adapted to injuries other than fractures when considering possible abuse.

Table 1. The ‘HITS’ of injury plausibility are four key questions that help address the plausibility of fracture or injury
H – History consistencyIs the history told consistently, or does the story change?
I – Injury compatibilityIs the fracture morphology compatible with the biomechanical loading required to produce that specific fracture type?
T – Timing congruencyIs the timing of the described development of signs, symptoms and actions congruent with the severity of the injury and the physiologic consequences produced by the fracture?
S – Skin findingsAre there bruises/other skin injuries that are consistent with the provided history, and do skin findings reflect accidental injuries or are they atypical and unexplained?

Reviewer: Kirsten Zahnow, kirsten_zahnow@health.qld.gov.au

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