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Abstract

BACKGROUND:

Fractures occurring at or near the distal tip of a hip prosthesis with a stable
femoral stem (Vancouver type-B fractures) are associated with many
complications because of the inherently unstable fracture pattern. Locking
compression plates use screws that lock into the plate allowing multiple points of
unicortical fixation. Such unicortical fixation may lower the risk of damage to the
cement mantle or a stable femoral stem during the treatment of a periprosthetic
femoral fracture. The purpose of this study was to analyze clinically and
radiographically a group of patients with a Vancouver type-B1 periprosthetic
femoral fracture treated with open reduction and internal fixation with use of a
locking compression plate.

abstrak
LATAR BELAKANG:

Fraktur terjadi pada atau dekat ujung distal dari prosthesis pinggul dengan
batang femoralis stabil (Vancouver fraktur tipe-B) berhubungan dengan banyak
komplikasi karena pola fraktur tidak stabil. Mengunci piring kompresi
menggunakan sekrup yang mengunci ke dalam piring yang memungkinkan
beberapa titik fiksasi unicortical. Fiksasi unicortical tersebut dapat menurunkan
risiko kerusakan pada mantel semen atau batang femoralis stabil selama
pengobatan patah tulang femur periprosthetic. Tujuan dari penelitian ini adalah
untuk menganalisis secara klinis dan radiografi sekelompok pasien dengan
Vancouver Jenis-B1 periprosthetic fraktur femoralis diobati dengan reduksi
terbuka dan fiksasi internal dengan menggunakan piring kompresi penguncian.

METHODS:

Fourteen consecutive patients (fourteen hips) with a Vancouver type-B1


periprosthetic femoral fracture were treated with a locking compression plate. There
were five men and nine women with an average age of sixty-eight years at the time
of fracture. All of the fractures occurred after a total hip arthroplasty performed with
cement, and eleven of the arthroplasties were revisions. In addition to the plate,
cortical strut allografts were used to stabilize five fractures. The patients were
assessed clinically and radiographically.

METODE:
Empat belas pasien berturut-turut (empat belas pinggul) dengan Vancouver Jenis-B1
periprosthetic fraktur femur diperlakukan dengan sepiring kompresi penguncian.
Ada lima laki-laki dan sembilan perempuan dengan usia rata-rata enam puluh
delapan tahun pada saat fraktur. Semua patah tulang terjadi setelah artroplasti
total pinggul dilakukan dengan semen, dan sebelas dari arthroplasties yang revisi.
Selain piring, Allografts strut kortikal yang digunakan untuk menstabilkan lima
patah tulang. Para pasien dinilai secara klinis dan radiografi.

RESULTS:

The average duration of follow-up was twenty months. Eight fractures healed
uneventfully at an average of 5.4 months. Three treatment constructs failed with
fracture of the plate within twelve months after surgery. An additional three
constructs also failed because of plate pullout. All failures except one occurred in
constructs in which a cortical strut allograft had not been utilized.

HASIL:
Durasi rata-rata tindak lanjut adalah dua puluh bulan. Delapan patah tulang sembuh
uneventfully pada rata-rata 5,4 bulan. Tiga konstruksi pengobatan gagal dengan
fraktur piring dalam waktu dua belas bulan setelah operasi. Tambahan tiga
konstruksi juga gagal karena piring penarikan. Semua kegagalan kecuali satu terjadi
di konstruksi di mana strut allograft kortikal belum dimanfaatkan.

CONCLUSIONS:

On the basis of the high failure rate in this series of patients, locking compression
plates do not appear to offer advantages over other types of plates in the treatment
of type-B1 periprosthetic femoral fractures. Despite the potential to preserve the
cement mantle, the locked screws did not appear to offer good pullout resistance in
this fracture type. We believe that supplementation with strut allografts should be
used routinely if this type of locking compression plate is selected to treat these
fractures

KESIMPULAN:
Atas dasar tingkat kegagalan yang tinggi dalam seri ini pasien, mengunci pelat
kompresi tidak muncul untuk menawarkan keunggulan dibandingkan jenis lain dari
piring dalam pengobatan patah tulang femur periprosthetic Jenis-B1. Meskipun
potensi untuk melestarikan mantel semen, sekrup terkunci tampaknya tidak
memberikan perlawanan penarikan baik dalam jenis fraktur ini. Kami percaya
bahwa suplementasi dengan Allografts strut harus digunakan secara rutin jika jenis
penguncian plat kompresi yang dipilih untuk mengobati patah tulang ini

AbstractIntroduction. Patients suffering a distal femoral fracture are at a high risk of


morbidity and mortality. Currently this cohort is not afforded the same resources as
those with hip fractures. This study aims to compare their mortality rates and
assess whether surgical intervention improves either outcome or mortality following
distal femoral fractures. Methods. Patients over sixty-five admitted with a distal
femoral fracture between June 2007 and 2012 were retrospectively identified.
Patients mobility was categorised as unaided, walking aid, zimmer frame, or
immobile. The 30-day, six-month, and one-year mortality rates were recorded for
this group as well as for hip fractures during the same period. Results. 68 patients
were included in the study. The mortality rate for all patients with distal femoral
fractures was 7% at 30 days, 26% at six months, and 38% at one year, higher than
hip fractures during the same period by 8%, 13%, and 18%, respectively. Patients
managed surgically had lower mortality rates and higher mobility levels. Conclusion.
Patients suffering a distal femoral fracture have a high mortality rate and surgical
intervention seems to improve both mobility and mortality.

AbstractIntroduction. Pasien yang menderita patah tulang femur distal berada pada
risiko tinggi morbiditas dan mortalitas. Saat kelompok ini tidak diberikan sumber
daya yang sama seperti orang-orang dengan patah tulang pinggul. Penelitian ini
bertujuan untuk membandingkan tingkat kematian mereka dan menilai apakah
intervensi bedah meningkatkan baik hasil atau kematian berikut patah tulang femur
distal. Metode. Pasien lebih enam puluh lima mengaku dengan fraktur femur distal
antara Juni 2007 dan 2012 secara retrospektif diidentifikasi. Mobilitas pasien
dikategorikan sebagai telanjang, berjalan bantuan, bingkai zimmer, atau bergerak.
30-hari, enam bulan, dan tingkat kematian satu tahun dicatat untuk kelompok ini
serta untuk patah tulang pinggul pada periode yang sama. Hasil. 68 pasien
dilibatkan dalam penelitian ini. Tingkat kematian untuk semua pasien dengan patah
tulang femur distal adalah 7% pada 30 hari, 26% pada enam bulan, dan 38% pada
satu tahun, lebih tinggi dari patah tulang pinggul pada periode yang sama sebesar
8%, 13%, dan 18%, masing-masing . Pasien dikelola pembedahan memiliki tingkat
kematian yang lebih rendah dan tingkat mobilitas tinggi. Kesimpulan. Pasien yang
menderita patah tulang femur distal memiliki tingkat kematian yang tinggi dan
intervensi bedah tampaknya meningkatkan mobilitas dan mortalitas.

PDF]introduction case report discussion / conclusions - seefort

seefort.eu/.../Atypical_femur_fracture_as_a_result_of_long_term_bispho...

by T Rebelo

Apr 30, 2015 - Regardless of that, there are increasing reports of atypical femur
fractures ... femoral shaft, and atypical femur fracture: a systematic review and
meta-analysis.
PDF] kasus pengenalan diskusi laporan / kesimpulan - seefort
seefort.eu /.../ Atypical_femur_fracture_as_a_result_of_long_term_bispho ...
oleh T Rebelo
Apr 30, 2015 - Terlepas dari itu, ada laporan peningkatan patah tulang femur
atipikal ... poros femoralis, dan patah tulang paha atipikal: review sistematis dan
meta-analisis.

Search Results
1. [PDF]Prevalence of abuse among young children with femur ...

www.biomedcentral.com/content/pdf/1471-2431-14-169.pdf

by JN Wood - 2014 - Cited by 3 - Related articles

Jul 2, 2014 - Methods: We conducted a systematic review of published articles written in


English between January 1990 and. July 2013 on femur fracture etiology in children ...

2. [PDF]Provisional PDF - Journal of Orthopaedic Surgery and ...

www.josr-online.com/content/pdf/s13018-015-0165-0.pdf

by Z Jia - 2015

Jan 14, 2015 - displaced femoral neck fractures: a systematic review and meta-analysis ...
We conducted a systematic review and meta-analysis of randomized controlled trials ...

3. [PDF]introduction case report discussion / conclusions - seefort

seefort.eu/.../Atypical_femur_fracture_as_a_result_of_long_term_bispho...

by T Rebelo

Apr 30, 2015 - Regardless of that, there are increasing reports of atypical femur
fractures ... femoral shaft, and atypical femur fracture: a systematic review and meta-
analysis.

4. Surgical Fixation of Vancouver Type B1 Periprosthetic ...

pdfs.journals.lww.com/.../Surgical_Fixation_of_Vancouver_Type_B1.11.p...

by N Dehghan - 2014 - Related articles


Nov 20, 2014 - Femur Fractures: A Systematic Review. Niloofar Dehghan, MD ...
investigation was to systematically review and compare the most commonly used
fixation ...

5. [PDF]Optimal timing of femur fracture stabilization in polytrauma ...

https://www.east.org/Content/.../longbone_stabilization_2014.pdf

by RR Gandhi - 2014 - Related articles

Jun 16, 2014 - systematic review and meta-analysis for the earlier question. RevMan
software ... current review was to update EAST's femur fracture stabilization guidelines

Hasil Pencarian

[PDF] Prevalensi penyalahgunaan kalangan anak-anak muda dengan femur ...


www.biomedcentral.com/content/pdf/1471-2431-14-169.pdf
oleh JN Kayu - 2014 - Dikutip oleh 3 - artikel terkait
Jul 2, 2014 - Metode: Kami melakukan tinjauan sistematis dari artikel yang
dipublikasikan ditulis dalam bahasa Inggris antara Januari 1990 dan. Juli 2013 pada
tulang paha patah etiologi pada anak-anak ...
[PDF] Sementara PDF - Journal of Bedah Ortopedi dan ...
www.josr-online.com/content/pdf/s13018-015-0165-0.pdf
oleh Z Jia - 2015
Jan 14, 2015 - pengungsi patah tulang leher femur: review sistematis dan meta-
analisis ... Kami melakukan tinjauan sistematis dan meta-analisis dari percobaan
terkontrol acak ...
[PDF] kasus pengenalan diskusi laporan / kesimpulan - seefort
seefort.eu /.../ Atypical_femur_fracture_as_a_result_of_long_term_bispho ...
oleh T Rebelo
Apr 30, 2015 - Terlepas dari itu, ada laporan peningkatan patah tulang femur
atipikal ... poros femoralis, dan patah tulang paha atipikal: review sistematis dan
meta-analisis.
Fiksasi bedah dari Vancouver Jenis B1 Periprosthetic ...
pdfs.journals.lww.com /.../ Surgical_Fixation_of_Vancouver_Type_B1.11.p ...
oleh N Dehghan - 2014 - artikel terkait
Nov 20, 2014 - Femur Fraktur: Sebuah Tinjauan sistematis. Niloofar Dehghan,
MD ... penyelidikan adalah untuk meninjau secara sistematis dan membandingkan
fiksasi paling umum digunakan ...
[PDF] waktu Optimal fraktur femur stabilisasi di politrauma ...
https://www.east.org/Content/.../longbone_stabilization_2014.pdf
oleh RR Gandhi - 2014 - artikel terkait
Jun 16, 2014 - tinjauan sistematis dan meta-analisis untuk pertanyaan
sebelumnya. Software RevMan ... Ulasan ini adalah untuk memperbarui pedoman
stabilisasi fraktur femur TIMUR dunia
PASAL PENELITIAN Open Access
Prevalensi penyalahgunaan kalangan anak-anak muda dengan
fraktur femur: review sistematis
Joanne N Kayu
1,2,3 *
, Oludolapo Fakeye
1
, Valerie Mondestin
1
, David M Rubin
1,2,3
, Russell Localio
4
dan Chris Feudtner
1,2,3
Abstrak
Latar Belakang:
Faktor klinis yang mempengaruhi kemungkinan penyalahgunaan pada anak dengan
fraktur femur belum baik
dijelaskan. Akibatnya, yang menetapkan anak-anak dengan patah tulang femur
menjamin evaluasi melanggar sulit.
Oleh karena itu tujuan dari penelitian ini adalah untuk memperkirakan proporsi dari
patah tulang femur pada anak-anak disebabkan
penyalahgunaan dan untuk mengidentifikasi demografi, cedera dan presentasi
karakteristik yang mempengaruhi probabilitas bahwa tulang paha
fraktur sekunder untuk penyalahgunaan.
Metode:
Kami melakukan kajian sistematis artikel yang dipublikasikan ditulis dalam bahasa
Inggris antara Januari 1990 dan
Juli 2013 pada tulang paha patah etiologi pada anak-anak kurang dari atau sama
dengan 5 tahun berdasarkan pencarian di PubMed /
MEDLINE dan CINAHL database. Ekstraksi data berdasarkan elemen data yang telah
ditetapkan dan penelitian termasuk
indikator kualitas. Sebuah meta-analisis tidak dilakukan karena belajar
heterogenitas penduduk.
Hasil:
Di seberang 24 studi ditinjau, ada total 10.717 anak-anak kurang dari atau sama
dengan 60 bulan
dengan fraktur femur. Di antara anak-anak berusia kurang dari 12 bulan dengan
semua jenis patah tulang femur, peneliti menemukan
tarif melanggar mulai dari 16,7% menjadi 35,2%. Di antara anak-anak berusia 12
bulan atau lebih dengan patah tulang femur, penyalahgunaan
Harga yang lebih rendah: dari 1,5% - 6,0%. Dalam beberapa penelitian, usia kurang
dari 12 bulan, status non-rawat jalan, curiga
sejarah, dan adanya cedera tambahan yang terkait dengan temuan
penyalahgunaan. Fraktur diaphyseal yang
terkait dengan rendah melanggar kejadian dalam beberapa studi. Sisi fraktur dan
spiral jenis fraktur, bagaimanapun,
tidak terkait dengan penyalahgunaan.
Kesimpulan:
Studi umumnya menemukan proporsi yang tinggi dari pelecehan di kalangan anak-
anak berusia kurang dari 12 bulan dengan
fraktur femur. Sejarah trauma melaporkan, temuan pemeriksaan fisik dan hasil
radiologis harus
diperiksa untuk karakteristik yang meningkatkan atau menurunkan kemungkinan
penentuan penyalahgunaan.
Kata kunci:
Pelecehan anak, anak penganiayaan, fraktur Femur, Kecelakaan, Trauma
Latar belakang
Patah tulang paha adalah cedera ortopedi yang paling umum
yang anak-anak dirawat di rumah sakit di Amerika Serikat
[1,2]. Meskipun sebagian besar masa kanak-kanak femur fraktur
membangun struktur hasil dari trauma kecelakaan, melanggar juga com- sebuah
Penyebab mon fraktur ini, terutama pada anak-anak kurang
dari 1 tahun. Dengan demikian, penyedia medis merawat anak
anak dengan fraktur femur harus mengenali dan mengevaluasi
anak-anak yang mungkin korban pelecehan. Evaluasi penyalahgunaan
dan tingkat diagnosis antara anak-anak dengan fraktur femur
telah, bagaimanapun, telah tercatat bervariasi antara rumah sakit dan
penyedia [3-6]. Selain itu, penelitian telah menunjukkan bahwa
gagal untuk mengenali dan mengevaluasi karena melanggar di muda
anak-anak dengan patah tulang dapat mengakibatkan anak menderita
komplikasi dari cedera terdiagnosis tambahan
juga melanggar sebagai yang sedang berlangsung [7].
Meskipun fraktur femur telah dikaitkan, di
umum, dengan risiko penyalahgunaan tinggi pada anak-anak, [8-10]
prevalensi penyalahgunaan pada anak-anak dengan berbagai jenis
fraktur femur belum ditetapkan. Selain itu,
Gambaran klinis lain yang menambah atau mengurangi
kemungkinan penentuan kekerasan pada anak-anak dengan femur
fraktur belum juga el
ucidated. Ketidakpastian ini
* Korespondensi:
woodjo@email.chop.edu
1
Divisi Umum Pediatrics dan PolicyLab, The Children
'
sHospitalof
Philadelphia, 3535 Market Street, Lantai 15, Philadelphia PA19104, Pennsylvania
2
Leonard Davis Institut Ekonomi Kesehatan, Colonial Penn Center, 3641
Locust Walk, Philadelphia 19104, Pennsylvania
Daftar lengkap informasi penulis tersedia di akhir artikel
2014 Wood et al .; lisensi BioMed Central Ltd Ini adalah artikel Open Access
didistribusikan di bawah ketentuan Creative
Atribusi Commons License (http://creativecommons.org/licenses/by/2.0), yang
memungkinkan penggunaan tak terbatas, distribusi, dan
reproduksi dalam media apapun, asalkan karya asli dikreditkan dengan benar.
Creative Commons Public Domain
Dedikasi pengabaian (http://creativecommons.org/publicdomain/zero/1.0/) berlaku
untuk data yang tersedia dalam artikel ini,
kecuali dinyatakan lain.
Kayu
et al. BMC Pediatrics
2014,
14
: 169
http://www.biomedcentral.com/1471-2431/14/169
tentang yang anak-anak dengan patah tulang femur mungkin memiliki
telah disalahgunakan dapat menyebabkan variasi dalam perawatan dan tidak
terjawab
peluang untuk mendiagnosa penyalahgunaan
dalam populasi anak.
Mengingat ketidakpastian ini, kami sistematis
penelitian yang diterbitkan dalam rangka: 1) memberikan perkiraan
penyalahgunaan prevalensi anak

5 tahun dengan
fraktur femur dan 2) menggambarkan asosiasi spe
Gambaran klinis cific dengan kemungkinan penyalahgunaan menetukan
asi. Menyadari bahwa sebagian besar kasar
fraktur terjadi pada bayi dan balita muda, kita di-
anak menyimpulkan sampai usia 5 tahun di review kami sebagai penyalahgunaan
fraktur telah kadang-kadang dilaporkan di usia prasekolah
anak [10-13]. Karena heterogenitas studi popu-
lations, kami tidak melakukan meta-analisis. Sebaliknya, kita
menyajikan proporsi anak-anak didiagnosis dengan penyalahgunaan
di setiap studi serta rincian dari populasi penelitian, di
Untuk memberikan pemahaman yang lebih kaya dari prevalensi
penyalahgunaan di sub-populasi yang berbeda dari anak-anak dengan
fraktur femur.
Metode
Strategi pencarian
Sebuah tinjauan sistematis literatur tentang pelecehan pada anak-anak
dengan patah tulang dilakukan dengan menggunakan pra-ditentukan protokol
dengan dimasukkannya kriteria (tersedia atas permintaan). Makalah ini
mencakup bagian dari artikel khusus untuk tulang paha patah tulang
(Gambar 1). Kami melakukan pencarian untuk studi yang diterbitkan
dalam bahasa Inggris antara Januari 1990 dan Juli 2013 di
PubMed / MEDLINE dan database CINAHL menggunakan
istilah pencarian yang tercantum dalam berkas tambahan 1. Kami termasuk
istilah yang terkait dengan baik penyalahgunaan dan trauma kecelakaan untuk
menghindari bias terhadap penelitian difokuskan secara eksklusif pada
penyalahgunaan.
Studi juga diidentifikasi oleh iteratif meninjau
daftar referensi dari artikel id
entified selama pencarian.
Temukan studi
Percobaan acak terkontrol (RCT), calon non
Studi RCT, dan analisis data retrospektif yang di-
menyimpulkan; survei, ulasan, editorial, serangkaian kasus dan text
buku dikeluarkan. Studi dimasukkan jika subyek
adalah

5 tahun atau jika data untuk subset dari anak


anak

5 tahun bisa diambil. Studi termasuk


kurang dari 10 anak-anak

Tua dengan femur fraktur 5 tahun


membangun struktur dikeluarkan, seperti hewan dan post-mortem
studi. Studi metodologis lemah karena signifikan yang ada
Bias ficant dalam pemilihan mata pelajaran, seperti studi
termasuk hanya kasus dilihat oleh penyidik untuk
tinjauan medis-hukum atau studi termasuk hanya subset
pasien yang memenuhi syarat untuk pengobatan khusus mo-
dality, dikeluarkan. Judul dan abstrak penelitian yang
disaring oleh salah satu dari empat ulasan (JW, OF, Maria Fatima
de Reyes, VM), dan studi non-relevan dihilangkan
(Gambar 1). Naskah penuh untuk studi yang relevan yang
dinilai untuk kelayakan oleh dua ulasan (JW dan OF atau
VM) secara standar unblinded, dengan dis
perjanjian diselesaikan melalui konsensus.
Ekstraksi data, penilaian kualitas metodologi,
dan analisis
Dua ulasan (JW, OF) secara independen diekstrak
Informasi berikut dari penelitian menggunakan standar-a
ized bentuk: 1) karakteristik populasi penelitian (usia, jenis
(S) dari patah tulang, lokasi studi dan tanggal), 2) inklusi
dan kriteria eksklusi untuk mata pelajaran, 3) potensi bias, dan
4) jumlah patah tulang dikaitkan dengan kekerasan dan kecelakaan
mekanisme dalam populasi penelitian secara keseluruhan serta dalam
subpopulasi studi. Pengulas menilai tingkat
bukti yang disajikan dalam setiap studi menggunakan 2011 Oxford
Pusat Kedokteran (CEBM) Tingkat Bukti Berbasis
Tabel bukti (Tabel 1). Per Bukti CEBM
Tingkat, artikel memberikan bukti kuat yang
kemungkinan akan dinilai sebagai level 1, dan mereka menyediakan
bukti terlemah kemungkinan akan dinilai sebagai tingkat
5 [14,15]. Tingkat CEBM Bukti
"
Bagaimana com-
mon adalah masalah
"
yang diterapkan untuk studi tentang
prevalensi penyalahgunaan pada anak dengan fraktur femur.
Tingkat CEBM Bukti untuk studi diagnosis yang
disesuaikan untuk menilai studi meneliti asosiasi
fitur klinis tertentu dengan kemungkinan penyalahgunaan
penentuan. Studi memberikan informasi pada kedua
pertanyaan ditugaskan skor tunggal berdasarkan
pertanyaan yang mereka memiliki level terlemah dari bukti-
dence. Tingkat bukti ditugaskan untuk studi adalah spe
cific ke tingkat bukti untuk menjawab pertanyaan-pertanyaan
diajukan dalam review ini dan mungkin tidak mencerminkan
kualitas keseluruhan dari penelitian. Sebagai contoh, tingkat
Bukti diturunkan untuk studi dengan num kecil
bersof anak dengan fraktur femur meskipun-penelitian yang
ies mungkin memiliki metode yang tepat dan studi besar
populasi yang termasuk anak-anak dengan jenis lain
patah tulang. Demikian pula, penelitian diklasifikasikan sebagai non
saat ini dan menerima tingkat yang lebih rendah jika ada data yang
dari sebelum tahun 2000. Akhirnya, Tingkat CEBM Bukti
untuk studi prevalensi mencakup penilaian apakah
populasi penelitian lokal atau tidak, tapi kami memilih untuk
menghilangkan faktor ini karena kami tidak mencoba untuk memperkirakan
kawin prevalensi penyalahgunaan di lokasi tertentu. In-
manfaat kami menyediakan lokasi masing-masing studi dan menyerahkan kepada
pembaca untuk menentukan penerapan data penelitian
populasi minat mereka. Untuk setiap studi, ulang yang
pemirsa juga dinilai metodologi yang digunakan untuk menentukan bahwa
cedera adalah karena penyalahgunaan menggunakan skala diadaptasi dari
Maguire et al. [16] yang ditugaskan peringkat tertinggi (1) ke
Studi membutuhkan pelecehan yang akan baik dikonfirmasi pada anak
konferensi kasus penyalahgunaan atau perdata atau pidana proceed- pengadilan
ings, atau diakui oleh pelaku, atau menyaksikan. Itu
rank (5) terendah diberikan kepada penelitian tidak menyediakan
Kriteria lain untuk categoriz
ing kasus seperti dugaan penyalahgunaan
Kayu
et al. BMC Pediatrics
2014,
14
: 169
Halaman 2 dari 13
http://www.biomedcentral.com/1471-2431/14/169
(Tabel 2). Reviewer diselesaikan perbedaan pendapat melalui
diskusi dan konsensus.
Penyalahgunaan prevalensi untuk setiap studi dihitung
dengan interval kepercayaan 95% (CI) dari data yang kembali
porting dalam kelompok dan studi cross-sectional. Study- The
sensitivitas tertentu, spesifisitas, kemungkinan positif dan
rasio kemungkinan negatif dengan 95% CI yang berbeda
karakteristik klinis karena melanggar juga dihitung.
Formula dijelaskan oleh Simel et al. [17] diterapkan untuk
menghitung 95% CI untuk rasio kemungkinan. Semua analisis lainnya
dilakukan dengan menggunakan Stata 12 (StataCorp, College Station,
TX). Pilihan Pelaporan Produk untuk Ulasan sistematis
dan Meta-Analisis (PRISMA) checklist yang digunakan dalam
melaporkan hasil review sistematis (Tambahan
mengajukan 2).
Hasil
Deskripsi studi
Pencarian literatur yang komprehensif diidentifikasi 7009
non-duplikat kutipan pada semua patah tulang, yang 271 adalah
dianggap relevan. Dua puluh empat studi tentang patah tulang femur
kriteria inklusi bertemu (Gambar 1). [2,4-6,10,18-36] Total A
Tabel skala penilaian metodologi 1 Studi; tingkat skala bukti *
Pertanyaan Bagaimana umum adalah kekerasan fisik? Apakah faktor ini dikaitkan
dengan risiko kekerasan fisik?
Level 1 survei sekarang sampel acak (atau sensus) tinjauan sistematik dari studi
cross sectional dengan mengacu diterapkan secara konsisten
standar dan membutakan
Level 2 tinjauan sistematik dari survei yang memungkinkan cocok untuk lokal
keadaan
Individu studi cross sectional dengan standar referensi diterapkan secara konsisten
dan membutakan
Level 3 Non-acak atau tidak lancar sampel penelitian Non-berturut-turut, atau studi
tanpa referensi diterapkan secara konsisten
standar
Level 4 Kasus-seri Case
-
Studi kontrol, atau
"
standar referensi buruk atau non-independen
Level 5 n / a penalaran berbasis Mekanisme
* Diadaptasi dari 2011 Tingkat Oxford CEBM Bukti meja Bukti [
14
]. Tingkat dapat dinilai di atas dasar kualitas penelitian, ketidaktepatan,
indirectness,
atau karena efek ukuran mutlak sangat kecil. Saat didefinisikan sebagai data dari
tahun 2000 atau lambat.
Gambar 1
Proses identifikasi studi, skrining, penilaian kelayakan dan inklusi.
Kayu
et al. BMC Pediatrics
2014,
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Halaman 3 dari 13
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dari 10.717 anak-anak dari usia 0
-
5 dengan patah tulang femur yang
diperiksa dalam 24 studi. T
wo penelitian menggunakan nasional
database [10.19] menerima kualitas metodologi studi
Peringkat dari L1, 1 studi [31] menerima rating L2, 3
Studi [2,20,24] menerima rating dari L5, dan kembali pada
mainder studi memperoleh peringkat L3 atau L4 (Tabel 3)
[4-6,18,21-23,25-30,32-36]. Tiga studi yang mengharuskan
penyalahgunaan dikonfirmasi oleh konferensi kasus atau pengadilan proceed-
temuan berikut anak pelindung
layanan (CPS) investigasi
memperoleh peringkat 1 untuk ab
menggunakan metode penentuan
[18,22,26]. Sepuluh studi repor
ted cri- klinis spesifik
teria diterapkan dalam mendiagnosis melanggar (Peringkat 2 atau 3)
[4,20,21,24,25,29-31,33,36]. Sebelas studi, termasuk 8
Studi mengandalkan data administrasi, menerima pelecehan mencegah-
peringkat mination dari 4 atau 5 [2,
5,6,10,19,23,27,
28,32,34,35].
Kriteria inklusi dan eksklusi diterapkan dalam subjek
Temukan bervariasi antara 24 studi, dengan perbedaan
dalam jenis patah tulang femur dan kemungkinan etiologi
dipertimbangkan. Hanya 5 studi termasuk anak-anak dengan
Jenis fraktur femur dari setiap etiologi [10,19,21,27,36].
Tiga belas studi anak dikecualikan dengan fraktur patologis
membangun struktur dan / atau anak-anak dengan cl yang
telinga disengaja etiologi seperti
sebagai kecelakaan kendaraan bermotor (MVC)
[2,5,6,18,20,
22,26,30,32-35].
Delapan anak termasuk dengan jenis tertentu dari patah tulang atau
sejarah trauma melaporkan tertentu [22,23,25,26,28,31-34].
Tiga studi anak dikecualikan dengan cedera tambahan,
[4,22,26] berpotensi biasing penyalahgunaan prevalensi rendah.
Prevalensi penyalahgunaan pada anak-anak dengan fraktur femur:
semua jenis
Di antara penelitian termasuk anak-anak 0
-
36 bulan dengan semua
jenis patah tulang femur dari setiap dilaporkan etiologi, estimasi
prevalensi kawin patah tulang kasar berkisar antara 11,0% -
31,2% (Gambar 2) [4,10,21,29,30] Pengecualian dari MVC terkait
kasus meningkat kisaran melaporkan penyalahgunaan prevalensi di
studi ke 11,6% -50,0% [4,21,30]. Membatasi populasi yang
tion dalam studi ini untuk anak-anak <12 bulan mengakibatkan
berbagai 16,7% -30,5% melanggar prevalensi jika MVCs yang
termasuk [10,36] dan 16,7% -35,2% jika MVCs dikeluarkan
[5,6,30]. Satu studi yang termasuk kasus dikategorikan sebagai
"
pelecehan anak dicurigai
"
dalam trauma registry dan yang
menerima abus anak termurah
e Peringkat metodologi 5, ulang
porting prevalensi penyalahgunaan 68,3% pada anak-anak <18 bulan
lama [27]. Dalam sebuah penelitian anak-anak

36 bulan tua dengan


dilaporkan tangga sejarah jatuh, 13,8% anak dengan femur
fraktur dikategorikan sebagai disalahgunakan [31]. Di antara anak
anak> 12 bulan dengan semua typ
es fraktur femur, penyalahgunaan
didiagnosis atau dikonfirmasi di 1,5-6,0% kasus [10,18,30].
Probabilitas penyalahgunaan diagnosis pada anak-anak dengan
fraktur femur: Jenis diaphyseal
Dalam sebuah studi Swedia tunggal mengandalkan data administrasi,
4,2% dari anak-anak <12 bulan dengan femur diaphyseal
fraktur dikategorikan sebagai disalahgunakan (Gambar 3) [34]. Sebuah
penyalahgunaan prevalensi lebih tinggi, 13,7%, dilaporkan dalam
Studi Amerika anak-anak <24 bulan, juga mengandalkan
data administrasi [23]. Dua penelitian, satu Amerika
dan satu Thailand, melaporkan tingkat yang lebih tinggi dari yang diduga
melanggar antara anak-anak <60 bulan dengan non-MVC-
terkait diaphyseal fraktur femur: 31,6% dan 31,0% re-
spectively [32,33]. Dua penelitian difokuskan pada anak-anak dengan
fraktur femur diaphyseal dan tidak ada cedera tambahan re-
porting prevalensi rendah dari kasus dibuktikan sebagai abu-
Sive oleh Layanan Perlindungan Anak (CPS) dalam sampel mereka
(2,4% dan 7,9%) [22,26].
Probabilitas penyalahgunaan diagnosis pada anak-anak dengan
fraktur femur: distal Jenis metaphyseal
Dalam studi tunggal anak-anak <12 bulan dengan
distal fraktur metaphyseal lengkap, melanggar itu sus-
diharapkan dalam 75% dan didiagnosis pada 50% kasus [28].
Pasien dan keluarga demografi terkait dengan penyalahgunaan
penentuan
Umur <12 bulan dikaitkan dengan peningkatan penyalahgunaan likeli-
hood di 3 dari 5 studi, dengan rasio kemungkinan positif
mulai 3,3-19,7 (Tabl
e 4) [10,20,24,30,32]. Lain
mempelajari melaporkan peningkatan probabilitas penyalahgunaan antara
anak usia <18 bulan, dibandingkan dengan counter-
bagian

18 bulan [2]. Dua studi meneliti hubungan


kapal antara usia di tahun sebagai variabel kontinu dan
risiko penyalahgunaan: satu menemukan hubungan yang signifikan antara
Tabel skala penilaian metodologi 2 Studi; melanggar tekad Peringkat metodologi
skala *
1 Penyalahgunaan dikonfirmasi di konferensi kasus atau keluarga, saudara, atau
proses pengadilan pidana; diakui oleh pelaku; atau penyalahgunaan menyaksikan
2 Penyalahgunaan dikonfirmasi dengan kriteria menyatakan termasuk penilaian
multidisipliner
3a Penyalahgunaan didefinisikan menggunakan kriteria kasus dinyatakan
berdasarkan spesifik
Penyalahgunaan 3b termasuk kasus pelecehan kemungkinan atau kemungkinan
yang didefinisikan oleh kriteria kasus dinyatakan berdasarkan spesifik
4 Penyalahgunaan menyatakan tetapi tidak ada detail pendukung yang diberikan
tentang bagaimana penentuan penyalahgunaan dibuat
#
5 penyalahgunaan Diduga
* Diadaptasi dari skala dengan 5 tingkat yang dikembangkan oleh Maguire et al.
(2005). [
16
] Untuk studi menggunakan kriteria kasus berdasarkan menyatakan khusus untuk
membuat penentuan penyalahgunaan
(Peringkat 3), kami dibedakan studi yang disertakan hanya yang pasti kasus
penyalahgunaan (3a) dari orang-orang yang juga termasuk kemungkinan atau
kemungkinan penyalahgunaan kasus (3b). Sebuah
ssessment oleh
multidisiplin tim perlindungan anak berbasis rumah sakit sebagai bagian dari
perawatan klinis rutin tidak memenuhi syarat sebagai penilaian multidisiplin.
#
Level 4 meliputi studi mengandalkan
ICD-9 dan E-kode untuk mengidentifikasi kasus-kasus pelecehan di set data
administrasi dan studi mengandalkan diagnosa pelecehan yang dilakukan oleh tim
klinis tanpa pro
masi tertentu
kriteria yang diagnosa ini dibuat.
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Tabel 3 Ringkasan karakteristik studi
Studi (1
st
penulis, tahun) Studi Lokasi / Sumber Tanggal Umur
(Mo)
Penyertaan
kriteria
Pengecualian Studi Metode
Peringkat
sebuah
n
Dalton, 1990 [
4
] Cedera 3 Michigan Rumah Sakit, USA 1979-1983 <36 Femur fraktur semua jenis
lain
b
L4 / 3a 138
Thomas, 1991 [
20
] Rumah Sakit Yale-New Haven, Amerika Serikat 1997-1984 <36 Femur fraktur
patologis semua jenis fraktur L5 / 3b 25
c
Kowal-Vern, 1992 [
21
] Loyola University Medical Center, Amerika Serikat 1984-1989 <36 Femur fraktur
semua jenis ada L4 / 3a 14
c
Blakemore 1996 [
22
] C.S. Mott Anak
'
s Hospital, USA 1979-1993 12-
71
Terisolasi femur diaphyseal
patah tulang
Fraktur patologis, patah tulang MVC terkait,
cedera tambahan
b
L4 / 1 42
Hinton 1999 [
23
] Rumah Sakit Discharge database dari Maryland
Layanan Kesehatan Biaya Komisi Review, USA
1995-1996 <24 Femur fraktur diaphyseal fraktur Non-akut, beberapa penerimaan
L3 / 4 73
c
Rex 2000 [
24
] Manchester Anak-anak
'
s Rumah Sakit, Inggris 1992-1996 <60 Femur fraktur semua jenis,
melanggar pasti atau kecelakaan
Etiologi tidak jelas, patah tulang non-akut L5 / 3a 33
c
Scherl 2000 [
25
] The University of Chicago Anak
'
s Hospital &
Raja
'
s Hospital County, Amerika Serikat
1986-1996 <72 Ditutup femur diaphyseal
patah tulang
Fraktur non-diaphyseal, fraktur terbuka,
fraktur patologis
L3 / 2 207
Schwend 2000 [
26
] Anak-anak
'
s Hospital of Buffalo, New York, Amerika Serikat 1993-1997 <48 diaphyseal fraktur
femur fraktur patologis, cedera tambahan
b
L4 / 1,3b 139
Banaszkiewicz 2002 [
36
] Royal Aberdeen Anak
'
s Hospital, Inggris 1995-1999 <12 Femur fraktur semua jenis ada L4 / 3b 12
c
Jeerathanyasakun 2003 [
33
] Queen Sirikit National Institute of Child Health,
Thailand
1996-2001 <fraktur 60 diaphyseal femur fraktur Non-diaphyseal, greenstick distal
fraktur, fraktur patologis
L4 / 3b 39
Coffey 2005 [
27
] Anak-anak
'
s Hospital, Columbus, OH, USA 1998-2002 <18 Femur fraktur semua jenis None L4 /
5 41
c
Pierce, 2005 [
31
] Anak-anak
'
s Hospital of Pittsburgh, PA, USA 1999-2002

36 Femur fraktur semua jenis,


melaporkan sejarah tangga jatuh
Dilaporkan sejarah selain tangga jatuh L2 / 3a 29
Rewers 2005 [
35
] Colorado Trauma Registry, USA 1998-2001 <36 Femur fraktur patologis semua
jenis fraktur, non-Colorado
penduduk, ulangi masuk untuk komplikasi
L3 / 4 332
c
Loder 2006 [
19
] Nasional (
Anak
'
Database rawat inap,
USA) 2000 <24 Femur fraktur semua jenis ada L1 / 4 1.076
c
Arkader 2007 [
28
] Dua Tingkat I pusat pediatrik, USA 1995-2005

12 distal Lengkap
femur metaphyseal
patah tulang
Metaphyseal lengkap dan epifisis
fraktur
L3 / 4, 5 20
Trokel 2006 [
5
] Nasional (
Anak
'
Database rawat inap,
USA) 1997 <12 Femur fraktur semua jenis,
mengakui melalui ED
MVC, tembak, atau menusuk fraktur terkait;
tidak ada penyebab eksternal kode cedera
L3 / 4 426
c
Leventhal 2007 [
29
] Yale-New Haven Anak
'
s Hospital, CT, USA 1979-1983
1991
-
1994
1999-2002
<36 Femur fraktur patologis semua jenis fraktur L4 / 3b 81
c
Hui 2008 [
30
] Alberta Anak-anak
'
s Hospital, Kanada 1994-2005 <36 Femur fraktur patologis semua jenis fraktur L4 /
3b 127
Leventhal 2008 [
10
] Nasional (
Anak
'
Database rawat inap,
USA) 2003 <36 Femur fraktur semua jenis ada L1 / 4 4026
c
Baldwin 2011 [
2
] Anak-Anak
'
s Hospital of Philadelphia,
PA, USA
1998+ <48 Femur fraktur semua jenis fraktur patologis, penyebab fraktur tidak
jelas ditentukan
L5 / 4 209
Heideken 2011 [
34
] Rumah Sakit National Swedia Discharge Registry,
Swedia
1987-2005 <12 diaphyseal femur fraktur Non-diaphyseal fraktur, patologis atau
fraktur lahir, beberapa patah tulang femur
L3 / 4 313
c
Kayu
et al. BMC Pediatrics
2014,
14
: 169
Halaman 5 dari 13
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Tabel 3 Ringkasan karakteristik studi
(Lanjutan)
Shrader 2011 [
32
] Phoenix Anak-anak
'
s Hospital, AZ, USA 2003-2008 <60 diaphyseal fraktur femur fraktur patologis, non-
diaphyseal
fraktur
L3 / 4 137
Wood, 2012 [
6
] Pediatric Sistem Informasi Kesehatan database
(40 rumah sakit pediatrik), Amerika Serikat
1999-2009 <12 Femur fraktur semua jenis MVC, kelahiran, atau neoplasma terkait
patah tulang L3 / 4 2975
c
Capra, 2013 [
18
] The Hospital for Sick Children, Toronto,
Kanada
1995-2004 12-
59
Femur fraktur semua jenis Non anak rawat jalan, patologis
fraktur
L3 / 1 203
sebuah
Menyajikan peringkat keseluruhan metodologi studi (L1-L5) dan penyalahgunaan
peringkat metodologi penentuan (1
-
5). Lihat Tabel
1
untuk deskripsi dari skala peringkat. Beberapa penelitian digunakan beberapa
metode yang berbeda untuk mendefinisikan
kasus penyalahgunaan atau diduga melanggar dan karena itu menerima lebih dari
satu peringkat.
b
Pasien dengan luka lain (selain fraktur femur) dikeluarkan dari studi ini, tetapi
definisi yang tepat dari cedera tambahan var
ied.
c
Data yang disajikan adalah untuk bagian yang relevan dari populasi penelitian yang
lebih besar yang mungkin termasuk anak-anak dengan jenis lain dari cedera, usia
lain,
nd / atau dari periode waktu lainnya.
Kayu
et al. BMC Pediatrics
2014,
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: 169
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usia yang lebih muda dan meningkatkan risiko [26], tapi yang lain tidak
[22]. Status non-ambulatory dikaitkan dengan peningkatan
penyalahgunaan kemungkinan di kedua penelitian yang meneliti hubungan ini
[26,30].
Pria gender dan Medicaid / Status diasuransikan masing-masing
terkait dengan peningkatan kemungkinan penyalahgunaan kemungkinan
hanya dalam satu [2,32] beberapa penelitian yang meneliti ini
asosiasi [22,26,28,30,35]. Tidak ada hubungan yang ditemukan
antara penyalahgunaan kemungkinan dan ras [26,35]. Dalam satu
studi, skor rendah pada Hollingshead Kerja
Skala (HOS) untuk ayah, tetapi tidak ibu, yang diasosiakan
diciptakan dengan laporan ke CPS [22].
Karakteristik sejarah yang terkait dengan penyalahgunaan
Sejarah yang mencurigakan terkait dengan femur kasar
fraktur di 3 dari 3 penelitian (Tabel 5) [2,22,30]. Defin- The
ition sejarah mencurigakan bervariasi tetapi umumnya termasuk
sejarah tidak ada trauma, sejarah trauma Deidara, atau
sejarah dianggap tidak konsisten dengan cedera. Penundaan
dalam perawatan dari> 24 jam dan mekanisme trauma yang tidak diketahui
dikaitkan dengan penyalahgunaan, sementara-saksi sejarah trauma
nessed oleh non-orangtua dikaitkan dengan non-kasar
fraktur femur [22,30,32]. Dalam satu studi, cedera occur-
cincin di rumah atau lokasi yang tidak diketahui dikaitkan
dengan penyalahgunaan dibandingkan dengan cedera yang terjadi di depan umum
tempat [35].
Cedera tambahan yang terkait dengan penyalahgunaan
Cedera tambahan, termasuk memar, patah tulang lainnya
diidentifikasi pada survei kerangka, dan perdarahan subdural,
secara signifikan terkait dengan penentuan abu-
femur fraktur komprehensif di 3 dari 4 studi (Tabel 5
)
[2,30-32].
Screening universal untuk cedera tambahan, bagaimanapun,
tidak dilakukan dalam studi ini.
Karakteristik fraktur terkait dengan penyalahgunaan
Dalam 2 dari 3 penelitian, patah tulang diaphyseal dikaitkan
dengan penurunan penyalahgunaan kemungkinan, dibandingkan dengan fraktur
lainnya
jenis mendatang (Tabel 6) [2,30,35]. Fraktur diaphyseal distal,
dibandingkan dengan proksimal dan diaphyseal midshaft
Gambar 2
Probabilitas perlakuan pada Anak dengan Femur Fraktur, Semua Jenis.
Proporsi kasus dengan fraktur femur kasar di disertakan
penelitian, dengan kriteria usia subjek inklusi.
sebuah
Batas usia atas adalah 11 bulan di Leventhal [10] & Kayu [6] dan 12 bulan di Hui
[30].
b
Data untuk
hanya subset dari anak-anak mengaku anak
'
s rumah sakit atau ke rumah sakit umum tanpa anak-anak
'
rumah sakit s bisa diambil.
c
Studi itu
terbatas pada anak-anak dengan femur fraktur terisolasi dan tidak ada cedera
tambahan.
d
Termasuk anak-anak dengan melaporkan sejarah tangga jatuh

36 bulan
saja.
e
Menyajikan peringkat keseluruhan metodologi studi (L1-L5) dan penyalahgunaan
peringkat metodologi penentuan (1
-
5).
Kayu
et al. BMC Pediatrics
2014,
14
: 169
Halaman 7 dari 13
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patah tulang, dikaitkan dengan penyalahgunaan dalam penelitian lain
[26]. Dalam satu laporan, fraktur metaphyseal distal menunjukkan
peningkatan probabilitas melanggar [2], namun temuan ini tidak
direplikasi dalam studi kedua [30]. Sisi fraktur, spiral
Jenis fraktur, atau bilateral patah tulang tidak menunjukkan signifikan
asosiasi tidak bisa dengan melanggar [22,26,28,30].
Diskusi
Review kami mengidentifikasi 24 studi memberikan informasi
tentang prevalensi penyalahgunaan kalangan anak-anak muda dengan
fraktur femur. Penyalahgunaan dikonfirmasi atau diduga
prevalensi bervariasi secara luas di seluruh studi dengan titik
Perkiraan berkisar antara 1,5% - 68,3%, yang mencerminkan het- yang
erogeneity studi
'
populasi dan methodolo-
gies. Struktur ulasan ini, dengan fokus pada yang lebih kecil
kelompok studi dengan populasi yang sama dan ketat
metode penentuan pelecehan anak, diproduksi sempit
rentang penyalahgunaan proporsi.
Hasil penelitian kami menunjukkan bahwa ada risiko substansial
melanggar (16,7% - 35,5%) pada anak-anak <12 bulan dengan
non-MVC terkait patah tulang femur. Prevalensi penyalahgunaan
dalam kelompok usia ini lebih rendah, namun, dari 50,1%
(95% CI, 34,1-66,1) dilaporkan untuk anak-anak <18 bulan di
meta-analisis terbaru oleh Maguire et al., [8] mungkin karena
perbedaan dalam strategi pencarian dan kriteria inklusi. Kita
trauma kecelakaan termasuk serta trauma kasar
istilah pencarian untuk mencegah bias terhadap penelitian difokuskan pada
patah tulang kasar saja. Selain itu, kami terbatas kami
mencari untuk artikel yang dipublikasikan pada tahun 1990 atau lambat, sementara
Maguire et al. termasuk makalah sebelumnya. Meskipun
kerangka waktu yang lebih singkat untuk review kami mungkin telah dikecualikan
makalah yang relevan, kita termasuk hanya makalah yang diterbitkan setelah
1990 karena dua alasan penting. Pertama, data menunjukkan bahwa
probabilitas penyalahgunaan antara anak-anak dengan fraktur memiliki
berubah dari waktu ke waktu [29]. Kedua, materi pelajaran adalah
dieksplorasi sebagian besar dalam studi retrospektif yang tergantung
pada praktek evaluasi klinis yang mungkin telah berubah
lembur. Pelecehan anak merupakan bidang yang relatif baru; banyak
pusat pediatrik tidak membangun program pelecehan anak
sampai setelah tahun 1990 [37]. Akhirnya, perkiraan kami untuk prevalence
lence fraktur femur kasar termasuk data dari
kohort dan studi cross-sectional, sedangkan Maguire et al.
juga ekstrapolasi dari kasus
-
studi kontrol. Meskipun
dua ulasan memberikan perkiraan titik yang berbeda, baik
ditemukan prevalensi tinggi penyalahgunaan pada anak <12 bulan
tua dengan fraktur femur.
Hasil review ini juga menekankan signifikan yang
cance dilaporkan sejarah dan adanya tambahan
cedera untuk penentuan kekerasan pada anak-anak dengan
fraktur femur. Femur jenis fraktur dan posisi yang,
pada umumnya, tidak secara signifikan terkait dengan penyalahgunaan, dengan
pengecualian bahwa patah tulang diaphyseal dan pertengahan /-proxy
diaphyseal fraktur Imal terutama mungkin terkait
dengan penurunan penyalahgunaan kemungkinan. Di sisi lain,
Gambar 3
Probabilitas perlakuan pada Anak dengan diaphyseal Femur Fraktur.
sebuah
Penelitian terbatas pada anak-anak dengan patah tulang femur terisolasi
tanpa cedera tambahan.
b
Menyajikan peringkat keseluruhan metodologi studi (L1-L5) dan penyalahgunaan
peringkat metodologi penentuan (1
-
5).
Kayu
et al. BMC Pediatrics
2014,
14
: 169
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Tabel 4 Asosiasi karakteristik demografi dengan kemungkinan penyalahgunaan
Karakteristik Sensitivitas Studi (95% CI) (95% CI) Spesifisitas (95% CI) LR + (95% CI)
LR- (95% CI)
P
sebuah
Usia
<12 m.o. vs 12 m.o.-35 m.o. Thomas, 1991 66,7 (35,9-97,5) 75,0 (53,8-96,2) 2,7
(1,0-7,0) 0,4 (0,2-1,2) 0,09
<12 m.o. vs 12 m.o.-35 m.o. Hui 2008 71,4 (47,8-95,1) 55,8 (46,6-64,9) 1,6 (1,1-
2,4) 0,5 (0,2-1,2) 0,09
b
<12 m.o. vs 12 m.o.-35 m.o. Leventhal 2008 81,6 (78,0-85,0) 75,4 (74,0-76,8) 3,3
(3,1-3,6) 0,2 (0,2-0,3)
<0,001
<12 m.o. vs 12 m.o.-59 m.o. Rex, 2000 92,9 (79.4-100.0) 73,7 (53.9.-93,5) 3,5 (1.6-
7.6) 0,1 (0.0-0.7)
<0,001
<12 m.o. vs 12 m.o.-71 m.o. Shrader 2011 41,9 (27,1-56,6) 97,9 (95,0-100,0) 19,7
(4,8-81) 0,6 (0,5-0,8)
<0,001
<18 m.o. vs 18 m.o.-47 m.o. Baldwin 2011 90,0 (83,0-97,0) 68,3 (60,6-76,1) 2,8
(2,2-3,7) 0,1 (0,1-0,3)
<0,001
Status Ambulatory
Non-rawat vs rawat Schwend 2000 76,9 (54,0-99,8) 88,1 (82,4-93,7) 6,5 (3,7-11,3)
0,3 (0,1-0,7)
<0,001
Non-rawat vs rawat Hui 2008 71,4 (47,8-95,1) 69,0 (60,5-77,6) 2,3 (1,5-3,5) 0,4
(0,2-1,0)
0,006
Status Asuransi Kesehatan
Vs diasuransikan diasuransikan Baldwin 2011 7.1 (1,2-13,2) 90,6 (85,8-95,5) 0,8
(0,3-2,0) 1,0 (0,9-1,1) 0.80
Diasuransikan / Medicaid vs Shrader swasta 2011 76,7 (64,1-89,4) 51,1 (41,0-61,2)
1,6 (1,2-2,0) 0,5 (0,3-0,8)
0,003
Diasuransikan / Medicaid vs Blakemore swasta 1996 37,5 (13,8-61,2) 88,5 (76,2-
100,0) 3,3 (0,9-11,2) 0,7 (0,5-1,1) 0,06
Jenis kelamin
Pria vs wanita Schwend 2000 61,5 (35,1-88,0) 27,8 (20,0-35,6) 0,9 (0,5-1,3) 1,4
(0,7-2,9) 0,52
Pria vs wanita Baldwin 2011 51,4 (39,7-63,1) 32,4 (24,6-40,2) 0,8 (0,6-1,0) 1,5 (1,1-
2,1)
0,002
Pria vs perempuan Hui 2008 50,0 (23,8-76,2) 37,2 (28,3-46,1) 1,2 (0,7-2,0) 0,8 (0,5-
1,4) 0,39
Pria vs wanita Rewers 2005 62,5 (48,4-76,2) 31,7 (26,2-37,1) 0,9 (0,7-1,2) 1,2 (0,8-
1,8) 0.51
Pria vs wanita Arkader 2007 80,0 (55,2-100) 40,0 (9,6-70,4) 1,3 (0,7-2,4) 0,5 (0,1-
2,1) 0.63
Ras
Hitam vs Putih / lainnya Schwend 2000 46,2 (19,1-73,3) 77,0 (69,6-84,3) 2,0 (1,0-
3,9) 0,7 (0,4-1,2) 0,09
Hitam vs Putih / Hispanik / lainnya Rewers 2005 54,2 (40,1-68,3) 44,2 (38,4-50,1)
1,0 (0,7-1,3) 1,0 (0,7-1,4) 0.88
sebuah
Dihitung dengan menggunakan dua sisi Fisher
'
s exact test.
P
-values 0,05 atau kurang dianggap signifikan secara statistik dan disajikan dalam
teks tebal.
b
P
-Nilai dilaporkan di Hui [
30
] Kertas adalah 0,037 tetapi dihitung menjadi 0,09 menggunakan dua sisi Fisher
'
s exact test.
Kayu
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Tabel 5 Asosiasi Sejarah & Pemeriksaan Karakteristik dengan Kemungkinan
Penyalahgunaan
Karakteristik Sensitivitas Studi (95% CI) Spesifisitas (95% CI) LR + (95% CI) LR-
(95% CI)
p
sebuah
Sejarah dilaporkan Trauma
c
Mencurigakan vs non-mencurigakan Blakemore 1996 68,7 (46,0-91,5) 88,0 (75,3-
100,0) 5,7 (1,9-17,4) 0,4 (0,2-0,7)
<0,001
Mencurigakan vs non-mencurigakan Baldwin 2011 32,9 (21,9-43,9) 95,7 (92,3-99,1)
7,6 (3,2-17,8) 0,7 (0,6-0,8)
<0,001
Mencurigakan vs non-mencurigakan Hui 2008 71,4 (47,8-95,1) 97,3 (94,4-100,0)
26,9 (8,4-86,2) 0,3 (0,1-0,7)
<0,001

RESEARCH ARTICLE Open Access


Prevalence of abuse among young children
with
femur fractures: a systematic review
Joanne N Wood
1,2,3*
, Oludolapo Fakeye
1
, Valerie Mondestin
1
, David M Rubin
1,2,3
, Russell Localio
4
and Chris Feudtner
1,2,3
Abstract
Background:
Clinical factors that affect the likelihood of abuse in children with femur fractures have not been well
elucidated. Consequently, specifying which children with femur fractures warrant an abuse evaluation is
difficult.
Therefore the purpose of this study is to estimate the proportion of femur fractures in young children
attributable
to abuse and to identify demographic, injury and presentation characteristics that affect the probability
that femur
fractures are secondary to abuse.
Methods:
We conducted a systematic review of published articles written in English between January 1990 and
July 2013 on femur fracture etiology in children less than or equal to 5 years old based on searches in
PubMed/
MEDLINE and CINAHL databases. Data extraction was based on pre-defined data elements and included
study
quality indicators. A meta-analysis was not performed due to study population heterogeneity.
Results:
Across the 24 studies reviewed, there were a total of 10,717 children less than or equal to 60 months old
with femur fractures. Among children less than 12 months old with all types of femur fractures,
investigators found
abuse rates ranging from 16.7% to 35.2%. Among children 12 months old or greater with femur fractures,
abuse
rates were lower: from 1.5% - 6.0%. In multiple studies, age less than 12 months, non-ambulatory status,
a suspicious
history, and the presence of additional injuries were associated with findings of abuse. Diaphyseal
fractures were
associated with a lower abuse incidence in multiple studies. Fracture side and spiral fracture type,
however, were
not associated with abuse.
Conclusions:
Studies commonly find a high proportion of abuse among children less than 12 months old with
femur fractures. The reported trauma history, physical examination findings and radiologic results must be
examined for characteristics that increase or decrease the likelihood of abuse determination.
Keywords:
Child abuse, Child maltreatment, Femur fracture, Accident, Trauma
Background
Femur fractures are the most common orthopedic injury
for which children are hospitalized in the United States
[1,2]. Although the majority of childhood femur frac-
tures result from accidental trauma, abuse is also a com-
mon cause of these fractures, especially in children less
than 1 year old. Thus, medical providers caring for chil-
dren with femur fractures should recognize and evaluate
children who might be abuse victims. Abuse evaluation
and diagnosis rates among children with femur fractures
have, however, been noted to vary among hospitals and
providers [3-6]. Furthermore, studies have shown that
failing to recognize and evaluate for abuse in young
children with fractures can result in children suffering
complications from additional undiagnosed injuries as
well as ongoing abuse [7].
Although femur fractures have been associated, in
general, with a high abuse risk in young children, [8-10]
the prevalence of abuse in children with different types
of femur fractures has not been established. Moreover,
other clinical features that increase or decrease the
likelihood of abuse determination in children with femur
fractures have not been well el
ucidated. This uncertainty
* Correspondence:
woodjo@email.chop.edu
1
Division of General Pediatrics and PolicyLab, The Children

sHospitalof
Philadelphia, 3535 Market Street, Floor 15, Philadelphia PA19104, Pennsylvania
2
Leonard Davis Institute of Health Economics, Colonial Penn Center, 3641
Locust Walk, Philadelphia 19104, Pennsylvania
Full list of author information is available at the end of the article
2014 Wood et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Wood
et al. BMC Pediatrics
2014,
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:169
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regarding which children with femur fractures might have
been abused may contribute to variation in care and missed
opportunities to diagnose abuse
in the pediatric population.
Given these uncertainties, we systematically reviewed
published studies in order to: 1) provide estimates of
abuse prevalence among children

5 years old with


femur fractures and 2) describe the association of spe-
cific clinical features with likelihood of abuse determin-
ation. Recognizing that the vast majority of abusive
fractures occur in the infants and young toddlers, we in-
cluded children up to age 5 years in our review as abusive
fractures have been occasionally reported in preschool age
children [10-13]. Due to the heterogeneity of study popu-
lations, we did not perform a meta-analysis. Instead, we
present the proportions of children diagnosed with abuse
in each study as well as details of the study population, in
order to provide a richer understanding of the prevalence
of abuse in different sub-populations of children with
femur fractures.
Methods
Search strategy
A systematic review of the literature on abuse in children
with fractures was performed using a pre-specified protocol
with inclusion criteria (available upon request). This paper
covers the subset of articles specific to femur fractures
(Figure 1). We performed searches for studies published
in English between January 1990 and July 2013 in the
PubMed/MEDLINE and CINAHL databases using the
search terms listed in Additional file 1. We included
terms related to both abuse and accidental trauma to
avoid bias toward studies focused exclusively on abuse.
Studies were also identified by iteratively reviewing
reference lists of articles id
entified during the search.
Study selection
Randomized controlled trials (RCT), prospective non-
RCT studies, and retrospective data analyses were in-
cluded; surveys, reviews, editorials, case series and text-
books were excluded. Studies were included if subjects
were

5 years old or if the data for the subset of chil-


dren

5 years old could be extracted. Studies including


fewer than 10 children

5 years old with femur frac-


tures were excluded, as were animal and post-mortem
studies. Methodologically weak studies due to signi-
ficant bias in selection of subjects, such as studies
including only cases seen by the investigator for
medical-legal review or studies including only the subset
of patients who were eligible for a specific treatment mo-
dality, were excluded. Titles and abstracts of studies were
screened by one of four reviewers (JW, OF, Maria Fatima
de Reyes, VM), and non-relevant studies were eliminated
(Figure 1). Full manuscripts for relevant studies were
assessed for eligibility by two reviewers (JW and OF or
VM) in an unblinded standardized manner, with dis-
agreements resolved by consensus.
Data extraction, assessment of methodological quality,
and analysis
Two reviewers (JW, OF) independently extracted the
following information from the studies using a standard-
ized form: 1) study population characteristics (ages, type
(s) of fractures, study location and dates), 2) inclusion
and exclusion criteria for subjects, 3) potential biases, and
4) number of fractures attributed to abuse and accidental
mechanisms in overall study population as well as within
study subpopulations. The reviewers assessed the level of
the evidence presented in each study using the 2011 Oxford
Centre for Evidence-Based Medicine (CEBM) Levels of
Evidence table (Table 1). Per the CEBM Evidence
Levels, articles providing the strongest evidence are
likely to be assessed as a level 1, and those providing
the weakest evidence are likely to be assessed as a level
5 [14,15]. The CEBM Evidence Levels for

How com-
mon is the problem

were applied to studies of the


prevalence of abuse in children with femur fractures.
The CEBM Evidence Levels for diagnosis studies were
adapted for assessing studies examining the association
of specific clinical features with likelihood of abuse
determination. Studies providing information on both
questions were assigned a single score based on the
question for which they had the weakest level of evi-
dence. The level of evidence assigned to a study is spe-
cific to the level of evidence for answering the questions
posed in this review and may not be reflective of the
overall quality of the study. For example, the level of
evidence was downgraded for studies with small num-
bersof children with femur fractures although the stud-
ies may have had appropriate methods and large study
populations that included children with other types of
fractures. Similarly, studies were classified as non-
current and received a lower level if any of the data was
from prior to 2000. Finally, the CEBM Evidence Levels
for prevalence studies include assessment of whether
the study population is local or not, but we chose to
eliminate this factor as we were not attempting to esti-
mate the prevalence of abuse in a particular location. In-
stead we provide the location of each study and leave it to
the reader to determine the applicability of the study data
to their population of interest. For each study, the re-
viewers also rated the methodology used to determine that
an injury was due to abuse using a scale adapted from
Maguire et al. [16] which assigned the highest rank (1) to
studies requiring that abuse be either confirmed at a child
abuse case conference or civil or criminal court proceed-
ings, or admitted by a perpetrator, or witnessed. The
lowest rank (5) was accorded to studies providing no
stated criteria for categoriz
ing cases as suspected abuse
Wood
et al. BMC Pediatrics
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(Table 2). Reviewers resolved disagreements through
discussion and consensus.
The abuse prevalence for each study was calculated
with 95% confidence intervals (CIs) from the data re-
ported in cohort and cross-sectional studies. The study-
specific sensitivity, specificity, positive likelihood and
negative likelihood ratios with 95% CIs of different
clinical characteristics for abuse were also computed.
Formulae described by Simel et al. [17] were applied to
calculate 95% CIs for likelihood ratios. All other analyses
were performed using Stata 12 (StataCorp, College Station,
TX). The Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) checklist was utilized in
reporting the results of the systematic review (Additional
file 2).
Results
Description of studies
The comprehensive literature search identified 7,009
non-duplicate citations on all fractures, of which 271 were
deemed relevant. Twenty-four studies on femur fractures
met inclusion criteria (Figure 1). [2,4-6,10,18-36] A total
Table 1 Study methodology rating scales; levels of evidence scale*
Question How common is physical abuse? Is this factor associated with risk of physical abuse?
Level 1 Current random sample surveys (or censuses) Systematic review of cross sectional studies with consistently applied
reference
standard and blinding
Level 2 Systematic review of surveys that allow matching to local
circumstances
Individual cross sectional studies with consistently applied reference standard
and blinding
Level 3 Non-random or non-current sample Non-consecutive studies, or studies without consistently applied reference
standards
Level 4 Case-series Case

control studies, or

poor or non-independent reference standard


Level 5 n/a Mechanism-based reasoning
*Adapted from the 2011 Oxford CEBM Evidence Levels of Evidence table [
14
]. Level may be graded down on the basis of study quality, imprecision, indirectness,
or because the absolute effect size is very small. Current was defined as data from 2000 or later.
Figure 1
Processes of study identification, screening, eligibility assessment and inclusion.
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of 10,717 children of ages 0

5 with femur fractures were


examined in the 24 studies. T
wo studies using a national
database [10,19] received a study methodology quality
rating of L1, 1 study [31] received a rating of L2, 3
studies [2,20,24] received a rating of L5, and the re-
mainder of studies received ratings of L3 or L4 (Table 3)
[4-6,18,21-23,25-30,32-36]. Three studies requiring that
abuse be confirmed by case conference or court proceed-
ings following a child protective
services (CPS) investigation
received a rating of 1 for the ab
use determination methods
[18,22,26]. Ten studies repor
ted specific clinical cri-
teria applied in diagnosing abuse (rating 2 or 3)
[4,20,21,24,25,29-31,33,36]. Eleven studies, including 8
studies relying on administrative data, received abuse deter-
mination ratings of 4 or 5 [2,
5,6,10,19,23,27,
28,32,34,35].
The inclusion and exclusion criteria applied in subject
selection varied among the 24 studies, with differences
in the types of femur fractures and possible etiologies
considered. Only 5 studies included children with any
femur fracture type from any etiology [10,19,21,27,36].
Thirteen studies excluded children with pathologic frac-
tures and/or children with a cl
ear accidental etiology such
as motor vehicle crash (MVC)
[2,5,6,18,20,
22,26,30,32-35].
Eight included children with specific types of fractures or
specific reported trauma histories [22,23,25,26,28,31-34].
Three studies excluded children with additional injuries,
[4,22,26] potentially biasing the abuse prevalence lower.
Abuse prevalence in young children with femur fractures:
all types
Among studies including children 0

36 months with all


types of femur fractures from any reported etiology, esti-
mated prevalence of abusive fractures ranged from 11.0%-
31.2% (Figure 2) [4,10,21,29,30] Exclusion of MVC-related
cases increased the range of reported abuse prevalence in
the studies to 11.6%-50.0% [4,21,30]. Restricting the popula-
tion in these studies to children <12 months old resulted in
a range of 16.7%-30.5% abuse prevalence if MVCs were
included [10,36] and 16.7%-35.2% if MVCs were excluded
[5,6,30]. One study which included cases categorized as

child abuse suspected

in the trauma registry and which


received the lowest child abus
e methodology rating of 5, re-
ported an abuse prevalence of 68.3% in children <18 months
old [27]. In a study of children

36 months old with a


reported stair fall history, 13.8% of children with femur
fractures were categorized as abused [31]. Among chil-
dren >12 months old with all typ
es of femur fractures, abuse
was diagnosed or confirmed in 1.5-6.0% of cases [10,18,30].
Probability of abuse diagnosis in young children with
femur fractures: diaphyseal type
In a single Swedish study relying on administrative data,
4.2% of children <12 months old with diaphyseal femur
fractures were categorized as abused (Figure 3) [34]. A
higher abuse prevalence, 13.7%, was reported in an
American study of children <24 months old, also relying
on administrative data [23]. Two studies, one American
and one Thai, reported even higher rates of suspected
abuse among children <60 months old with non-MVC-
related diaphyseal femur fractures: 31.6% and 31.0% re-
spectively [32,33]. Two studies focused on children with
diaphyseal femur fractures and no additional injuries re-
ported lower prevalences of cases substantiated as abu-
sive by Child Protective Services (CPS) in their samples
(2.4% and 7.9%) [22,26].
Probability of abuse diagnosis in young children with
femur fractures: distal metaphyseal type
In the single study of children <12 months old with a
complete distal metaphyseal fracture, abuse was sus-
pected in 75% and diagnosed in 50% of cases [28].
Patient and family demographics associated with abuse
determination
Age <12 months was associated with increased abuse likeli-
hood in 3 of 5 studies, with positive likelihood ratios
ranging from 3.3-19.7 (Tabl
e 4) [10,20,24,30,32]. Another
study reported increased probability of abuse among
children aged <18 months, as compared to counter-
parts

18 months [2]. Two studies examined the relation-


ship between age in years as a continuous variable and
risk of abuse: one found significant association between
Table 2 Study methodology rating scales; abuse determination methodology rating scale*
1 Abuse confirmed at case conference or family, civil, or criminal court proceedings; admitted by perpetrator; or witnessed abuse
2 Abuse confirmed by stated criteria including multidisciplinary assessment
3a Abuse defined using specific stated case based criteria
3b Abuse including cases of likely or probable abuse defined by specific stated case based criteria
4 Abuse stated but no supporting detail given as to how a determination of abuse was made
#
5 Suspected abuse
*Adapted from a scale with 5 levels developed by Maguire et al. (2005). [
16
] For studies using specific stated case based criteria to make a determination of abuse
(rating 3), we distinguished studies that included only definite abuse cases (3a) from those that also included likely or probable abuse cases (3b). A
ssessment by
multidisciplinary hospital-based child protection team as part of routine clinical care did not qualify as multidisciplinary assessment.
#
Level 4 includes studies relying on
ICD-9 and E-codes for identifying abuse cases in administrative data sets and studies relying on diagnoses of abuse made by clinical teams without
pro
viding specific
criteria by which these diagnoses were made.
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Table 3 Summary of study characteristics
Study (1
st
author, year) Study Location/Source Dates Age
(mo)
Inclusion
criteria
Exclusions Study Methods
Ranking
a
n
Dalton, 1990 [
4
] 3 Michigan Hospitals, USA 1979-1983 <36 Femur fracture all types Additional injuries
b
L4 / 3a 138
Thomas, 1991 [
20
] Yale-New Haven Hospital, USA 1997-1984 <36 Femur fracture all types Pathologic fracture L5 / 3b 25
c
Kowal-Vern, 1992 [
21
] Loyola University Medical Center, USA 1984-1989 <36 Femur fracture all types None L4 / 3a 14
c
Blakemore, 1996 [
22
] C.S. Mott Children

s Hospital, USA 1979-1993 12-


71
Isolated femur diaphyseal
fracture
Pathologic fractures, MVC related fractures,
additional injuries
b
L4 / 1 42
Hinton, 1999 [
23
] Hospital Discharge Database of the Maryland
Health Services Cost Review Commission, USA
1995-1996 <24 Femur diaphyseal fractures Non-acute fracture, multiple admissions L3 / 4 73
c
Rex, 2000 [
24
] Manchester Children

s Hospitals, UK 1992-1996 <60 Femur fracture all types,


definite abuse or accident
Unclear etiology, non-acute fractures L5 / 3a 33
c
Scherl, 2000 [
25
] The University of Chicago Children

s Hospital &
King

s County Hospital, USA


1986-1996 <72 Closed diaphyseal femur
fracture
Non-diaphyseal fractures, open fracture,
pathologic fracture
L3 / 2 207
Schwend, 2000 [
26
] Children

s Hospital of Buffalo, New York, USA 1993-1997 <48 Diaphyseal femur fracture Pathologic fracture, additional injuries
b
L4 / 1,3b 139
Banaszkiewicz, 2002 [
36
] Royal Aberdeen Children

s Hospital, UK 1995-1999 <12 Femur fracture all types None L4 / 3b 12


c
Jeerathanyasakun, 2003 [
33
] Queen Sirikit National Institute of Child Health,
Thailand
1996-2001 <60 Diaphyseal femur fracture Non-diaphyseal fracture, distal greenstick
fracture, pathologic fracture
L4 / 3b 39
Coffey, 2005 [
27
] Children

s Hospital, Columbus, OH, USA 1998-2002 < 18 Femur fracture all types None L4 / 5 41
c
Pierce, 2005 [
31
] Children

s Hospital of Pittsburgh, PA, USA 1999-2002

36 Femur fracture all types,


reported history of stair fall
Reported history other than stair fall L2 / 3a 29
Rewers, 2005 [
35
] Colorado Trauma Registry, USA 1998-2001 <36 Femur fracture all types Pathologic fracture, non-Colorado
resident, repeat admission for complication
L3 / 4 332
c
Loder, 2006 [
19
] National (
Kids

Inpatient Database,
USA) 2000 < 24 Femur fracture all types None L1 /4 1,076
c
Arkader, 2007 [
28
] Two Level I pediatric centers, USA 1995-2005

12 Complete distal
metaphyseal femur
fracture
Incomplete metaphyseal and epiphyseal
fractures
L3 / 4, 5 20
Trokel, 2006 [
5
] National (
Kids

Inpatient Database,
USA) 1997 <12 Femur fracture all types,
admitted through ED
MVC, gunshot, or stabbing related fracture;
no external cause of injury code
L3 / 4 426
c
Leventhal, 2007 [
29
] Yale-New Haven Children

s Hospital, CT, USA 1979-1983


1991

1994
1999-2002
<36 Femur fracture all types Pathologic fracture L4 / 3b 81
c
Hui, 2008 [
30
] Alberta Children

s Hospital, Canada 1994-2005 <36 Femur fracture all types Pathologic fracture L4 / 3b 127
Leventhal, 2008 [
10
] National (
Kids

Inpatient Database,
USA) 2003 <36 Femur fracture all types None L1 / 4 4,026
c
Baldwin, 2011 [
2
] The Children

s Hospital of Philadelphia,
PA, USA
1998+ <48 Femur fracture all types Pathologic fracture, cause of fracture not
clearly determined
L5 / 4 209
Heideken, 2011 [
34
] Swedish National Hospital Discharge Registry,
Sweden
1987-2005 <12 Diaphyseal femur fracture Non-diaphyseal fracture, pathologic or
birth fracture, multiple femur fractures
L3 /4 313
c
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Table 3 Summary of study characteristics
(Continued)
Shrader, 2011 [
32
] Phoenix Children

s Hospital, AZ, USA 2003-2008 <60 Diaphyseal femur fracture Pathologic fractures, non-diaphyseal
fractures
L3 / 4 137
Wood, 2012 [
6
] Pediatric Health Information System Database
(40 pediatric hospitals), USA
1999-2009 <12 Femur fracture all types MVC, birth, or neoplasm related fractures L3 / 4 2,975
c
Capra, 2013 [
18
] The Hospital for Sick Children, Toronto,
Canada
1995-2004 12-
59
Femur fracture all types Non ambulatory children, pathological
fractures
L3 /1 203
a
Presents overall study methodology ranking (L1-L5) and abuse determination methodology ranking (1

5). See Table


1
for description of the ranking scales. Some studies utilized multiple different methods to define
cases of abuse or suspected abuse and therefore received more than one ranking.
b
Patients with other injuries (in addition to the femur fracture) were excluded from these studies but the exact definition of additional injuries var
ied.
c
The data presented are for the relevant subset of a larger study population which may have included children with other types of injuries, other ages, a
nd/or from other time periods.
Wood
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younger age and increased risk [26], but the other did not
[22]. Non-ambulatory status was associated with increased
abuse likelihood in both studies examining this association
[26,30].
Male gender and Medicaid/uninsured status were each
associated with increased likelihood of abuse likelihood
in only one [2,32] of several studies examining these
associations [22,26,28,30,35]. No association was found
between abuse likelihood and race [26,35]. In a single
study, lower scores on the Hollingshead Occupational
Scale (HOS) for fathers, but not mothers, were associ-
ated with reports to CPS [22].
History characteristics associated with abuse
A suspicious history was associated with abusive femur
fracture in 3 of 3 studies (Table 5) [2,22,30]. The defin-
ition of suspicious history varied but generally included
history of no trauma, an unwitnessed trauma history, or
a history considered inconsistent with the injury. Delay
in care of >24 hours and unknown trauma mechanism
were associated with abuse, while a trauma history wit-
nessed by a non-parent was associated with non-abusive
femur fracture [22,30,32]. In one study, injuries occur-
ring at home or an unknown location were associated
with abuse compared to injuries occurring in public
places [35].
Additional injuries associated with abuse
Additional injuries, including bruises, other fractures
identified on skeletal survey, and subdural hemorrhages,
were significantly associated with determination of abu-
sive femur fracture in 3 of 4 studies (Table 5
)
[2,30-32].
Universal screening for additional injuries was, however,
not performed in any of these studies.
Fracture characteristics associated with abuse
In 2 of 3 studies, diaphyseal fractures were associated
with decreased abuse likelihood, compared to other frac-
ture types (Table 6) [2,30,35]. Distal diaphyseal fractures,
in comparison with proximal and midshaft diaphyseal
Figure 2
Probability of Abuse in Children with a Femur Fracture, All Types.
Proportion of cases with abusive femur fractures in included
studies, by subject age criteria of inclusion.
a
Upper age limit was 11 months in Leventhal [10] & Wood [6] and 12 months in Hui [30].
b
Data for
only the subset of children admitted to children

s hospitals or to general hospitals without children

s hospitals could be extracted.


c
Study was
limited to children with isolated femur fracture and no additional injuries.
d
Included children with reported history of stair fall

36 months old
only.
e
Presents overall study methodology ranking (L1-L5) and abuse determination methodology ranking (1

5).
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fractures, were associated with abuse in another study
[26]. In one report, distal metaphyseal fractures showed
increased abuse probability [2], but this finding was not
replicated in a second study [30]. Fracture side, spiral
fracture type, or bilateral fractures did not show signifi-
cant association with abuse [22,26,28,30].
Discussion
Our review identified 24 studies providing information
about prevalence of abuse among young children with
femur fractures. The confirmed or suspected abuse
prevalence varied widely across the studies with point
estimates ranging from 1.5% - 68.3%, reflecting the het-
erogeneity of the studies

populations and methodolo-


gies. The structure of this review, focusing on smaller
groups of studies with similar populations and stricter
child abuse determination methods, produced narrower
ranges of abuse proportions.
Our results indicate that there is substantial risk of
abuse (16.7%- 35.5%) in children <12 months old with
non-MVC-related femur fractures. The abuse prevalence
in this age group was lower, however, than the 50.1%
(95% CI, 34.1-66.1) reported for children <18 months in
a recent meta-analysis by Maguire et al., [8] likely due to
differences in search strategy and inclusion criteria. We
included accidental trauma as well as abusive trauma
search terms to prevent bias towards studies focused on
abusive fractures alone. In addition, we limited our
search to articles published in 1990 or later, while
Maguire et al. included earlier papers. Although the
shorter time frame for our review may have excluded
relevant papers, we included only papers published after
1990 for two important reasons. First, data suggest that
the abuse probability among children with fractures has
changed over time [29]. Second, the subject matter is
explored mostly in retrospective studies which depend
upon clinical evaluation practices that may have changed
over time. Child abuse is a relatively new field; many
pediatric centers did not establish child abuse programs
until after 1990 [37]. Finally, our estimates for preva-
lence of abusive femur fractures included data from
cohort and cross-sectional studies, while Maguire et al.
also extrapolated from case

control studies. Although


the two reviews provide different point estimates, both
found a high prevalence of abuse in children <12 months
old with femur fractures.
The results of this review also emphasize the signifi-
cance of reported history and the presence of additional
injuries for abuse determination in young children with
femur fractures. Femur fracture type and position were,
in general, not significantly associated with abuse, with
the exception that diaphyseal fractures and mid/prox-
imal diaphyseal fractures particularly might be associated
with decreased abuse likelihood. On the other hand,
Figure 3
Probability of Abuse in Children with Diaphyseal Femur Fractures.
a
Study was limited to children with isolated femur fractures
without additional injuries.
b
Presents overall study methodology ranking (L1-L5) and abuse determination methodology ranking (1

5).
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Table 4 Association of demographic characteristics with likelihood of abuse
Characteristics Study Sensitivity (95% CI) (95%CI) Specificity (95%CI) LR+ (95% CI) LR- (95% CI)
P
a
Age
< 12 m.o. vs. 12 m.o.-35 m.o. Thomas, 1991 66.7 (35.9-97.5) 75.0 (53.8-96.2) 2.7 (1.0-7.0) 0.4 (0.2-1.2) 0.09
< 12 m.o. vs. 12 m.o.-35 m.o. Hui, 2008 71.4 (47.8-95.1) 55.8 (46.6-64.9) 1.6 (1.1-2.4) 0.5 (0.2-1.2) 0.09
b
< 12 m.o. vs. 12 m.o.-35 m.o. Leventhal, 2008 81.6 (78.0-85.0) 75.4 (74.0-76.8) 3.3 (3.1-3.6) 0.2 (0.2-0.3)
<0.001
< 12 m.o. vs. 12 m.o.-59 m.o. Rex, 2000 92.9 (79.4-100.0) 73.7 (53.9.-93.5) 3.5 (1.6-7.6) 0.1 (0.0-0.7)
<0.001
< 12 m.o. vs. 12 m.o.-71 m.o. Shrader, 2011 41.9 (27.1-56.6) 97.9 (95.0-100.0) 19.7 (4.8-81) 0.6 (0.5-0.8)
<0.001
< 18 m.o. vs. 18 m.o.-47 m.o. Baldwin, 2011 90.0 (83.0-97.0) 68.3 (60.6-76.1) 2.8 (2.2-3.7) 0.1 (0.1-0.3)
<0.001
Ambulatory Status
Non-ambulatory vs. ambulatory Schwend, 2000 76.9 (54.0-99.8) 88.1 (82.4-93.7) 6.5 (3.7-11.3) 0.3 (0.1-0.7)
<0.001
Non-ambulatory vs. ambulatory Hui, 2008 71.4 (47.8-95.1) 69.0 (60.5-77.6) 2.3 (1.5-3.5) 0.4 (0.2-1.0)
0.006
Health Insurance Status
Uninsured vs. insured Baldwin, 2011 7.1 (1.2-13.2) 90.6 (85.8-95.5) 0.8 (0.3-2.0) 1.0 (0.9-1.1) 0.80
Uninsured/Medicaid vs. private Shrader, 2011 76.7 (64.1-89.4) 51.1 (41.0-61.2) 1.6 (1.2-2.0) 0.5 (0.3-0.8)
0.003
Uninsured/Medicaid vs. private Blakemore, 1996 37.5 (13.8-61.2) 88.5 (76.2-100.0) 3.3 (0.9-11.2) 0.7 (0.5-1.1) 0.06
Gender
Male vs. female Schwend, 2000 61.5 (35.1-88.0) 27.8 (20.0-35.6) 0.9 (0.5-1.3) 1.4 (0.7-2.9) 0.52
Male vs. female Baldwin, 2011 51.4 (39.7-63.1) 32.4 (24.6-40.2) 0.8 (0.6-1.0) 1.5 (1.1-2.1)
0.002
Male vs. female Hui, 2008 50.0 (23.8-76.2) 37.2 (28.3-46.1) 1.2 (0.7-2.0) 0.8 (0.5-1.4) 0.39
Male vs. female Rewers, 2005 62.5 (48.4-76.2) 31.7 (26.2-37.1) 0.9 (0.7-1.2) 1.2 (0.8-1.8) 0.51
Male vs. female Arkader, 2007 80.0 (55.2-100) 40.0 (9.6-70.4) 1.3 (0.7-2.4) 0.5 (0.1-2.1) 0.63
Race
Black vs. White/other Schwend, 2000 46.2 (19.1-73.3) 77.0 (69.6-84.3) 2.0 (1.0-3.9) 0.7 (0.4-1.2) 0.09
Black vs. White/Hispanic/other Rewers, 2005 54.2 (40.1-68.3) 44.2 (38.4-50.1) 1.0 (0.7-1.3) 1.0 (0.7-1.4) 0.88
a
Computed using two-sided Fisher

s exact test.
P
-values of 0.05 or less were considered statistically significant and are presented in bold text.
b
P
-value reported in Hui [
30
] paper was 0.037 but calculated to be 0.09 using two-sided Fisher

s exact test.
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Table 5 Association of History & Examination Characteristics with Likelihood of Abuse
Characteristics Study Sensitivity (95%CI) Specificity (95%CI) LR+ (95% CI) LR- (95% CI)
p
a
Reported History of Trauma
c
Suspicious vs. non-suspicious Blakemore, 1996 68.7 (46.0-91.5) 88.0 (75.3-100.0) 5.7 (1.9-17.4) 0.4 (0.2-0.7)
<0.001
Suspicious vs. non-suspicious Baldwin, 2011 32.9 (21.9-43.9) 95.7 (92.3-99.1) 7.6 (3.2-17.8) 0.7 (0.6-0.8)
<0.001
Suspicious vs. non-suspicious Hui, 2008 71.4 (47.8-95.1) 97.3 (94.4-100.0) 26.9 (8.4-86.2) 0.3 (0.1-0.7)
<0.001
Unknown vs. known history Shrader, 2011 39.5 (24.9-54.1) 94.7 (90.1-99.2) 7.4 (2.9-18.8) 0.6 (0.5-0.8)
<0.001
Unwitnessed vs. witnessed Blakemore, 1996 43.8 (19.4-68.1) 72.0 (54.4 -89.6) 1.6 (0.7-3.6) 0.8 (0.5-1.3) 0.33
Witnessed by non-parent (yes vs. no) Blakemore, 1996 18.8 (0.0-37.9) 48.0 (28.4-67.6) 0.4 (0.1-1.1) 1.7 (1.1-2.7)
0.05
History of fall vs. other history Blakemore, 1996 93.8 (81.9-100.0) 26.9 (9.9-44.0) 1.3(1.0-1.7) 0.2 (0.0-1.7) 0.13
Reported time from injury to care
Delay >24 hours vs. no delay Hui, 2008 42.9 (16.9-68.8) 92.0 (87.0-97.0) 5.4 (2.3-12.9) 0.6 (0.4-1.0)
0.002
Location Injury Occurred
Home/unknown vs. public place
d
Rewers, 2005 97.9 (93.9-100) 22.5 (17.65-27.4) 1.2-1.4 0.1 (0.0-0.7)
<0.001
Additional Injuries
Fractures, bruises, or SDHs (yes vs. no) Hui, 2008 42.9 (16.9-68.8) 92.0 (87.0-97.0) 3.7 (1.7-8.2) 0.6 (0.4-1.0)
0.007
Bruises vs. no bruises Pierce, 2005 100 (NA
e
) 72.0 (NA
e
) 3.6 (1.9-6.7) 0.0 (NA)
0.01
b
Current polytrauma
e
(yes vs. no) Baldwin, 2011 52.9 (41.2-64.6) 92.1 (87.6-96.6) 6.7 (3.6-12.3) 0.5 (0.4-0.7)
<0.001
Occult injury on imaging (yes vs. no) Pierce, 2005 75.0 (19.4-99.4) 100.0 (86.0-100.0) NA 0.3(0.0-1.4)
0.001
Any Shrader, 2011 20.9 (8.8-33.1) 90.4 (84.5-96.4) 2.2 (0.9-5.1) 0.9 (0.7-1.0) 0.10
a
Computed using two-sided Fisher

s exact test.
P-
values of 0.05 or less were considered statistically significant and are presented in bold text.
b
P
-value reported in Pierce [
31
] was 0.055 but computed as 0.010 using two-sided Fisher

s exact test.
c
Definition of suspicious history generally included no known history of trauma, or a history of trauma that was unwitnessed or considered inconsiste
nt with the injury.
d
Public place included locations categorized as public, recreation, and street.
e
Current polytrauma was defined as another concurrent long bone, clavicle, axial fracture, or other body system injury that would require hospitaliz
ation.
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Table 6 Association of fracture characteristics with likelihood of abuse
Characteristics Study Sensitivity (95%CI) Specificity (95%CI) LR+ (95% CI) LR- (95% CI)
p
a
General Fracture Position
Diaphyseal vs. all other Hui, 2008 78.6 (57.1-100.0) 36.3 (27.4-45.1) 1.2 (0.9-1.7) 0.6 (0.2-1.7) 0.38
Diaphyseal vs. all other Rewers, 2005 58.3 (44.4-72.3) 22.4 (17.5-27.3) 0.8 (0.6-1.0) 1.9 (1.2-2.8)
0.007
Diaphyseal vs. all other Baldwin, 2011 44.4 (33.0-55.9) 33.8 (25.9-41.7) 0.7 (0.5-0.9) 1.6 (1.2-2.2)
0.003
Subtrochanteric vs. all other Hui, 2008 7.1 ( 0.0-20.6) 95.6 (91.8-99.4) 0.5 (0.1-1.8) 1.2 (0.9-1.5) 0.51
Subtrochanteric vs. all other Baldwin, 2011 19.4 (10.3-28.6) 86.3 (80.6-92.0) 1.4 (0.8-2.7) 0.9 (0.8-1.1) 0.32
Distal metaphyseal vs. all other Hui, 2008 14.3 (0.0-32.6) 70.8 (62.4-79.2) 0.5 (0.1-1.8) 1.2 (0.9-1.5) 0.35
Distal metaphyseal vs. all other Baldwin, 2011 36.1 (25.0-47.2) 79.9 (73.2-86.5) 1.8 (1.1-2.8) 0.8 (0.7-1.0)
0.02
Diaphyseal Fracture Position
Distal vs. mid/proximal Schwend, 2000 53.8 (26.7-80.9) 88.4 (82.7-94.1) 4.7 (2.3-9.4) 0.5 (0.3-0.9)
0.001
Diaphyseal Fracture Type
Spiral vs. non-spiral Blakemore, 1996 11119961996 68.8 (46.0-91.5) 11.5 (0.0-23.8) 0.8 (0.5-1.1) 2.7 (0.7-9.8) 0.23
Transverse vs. all other Pierce, 2005 75.0 (32.6-100.0) 84.0 (69.6-98.4) 4.7 (1.6-13.6) 0.3 (0.1-1.6) 0.03
Fracture Side
Left vs. right Schwend, 2000 58.3 (30.4-86.2) 39.5 (30.9-48.1) 1.0 (0.6-1.6) 1.1 (0.5-2.1) 1.00
Left vs. right Blakemore, 1996 37.5 (13.8-61.2) 46.2 (27.0-65.3) 0.7 (0.3-1.4) 1.4 (0.8-2.4) 0.35
Left vs. right Hui, 2008 57.1 (31.2-83.1) 52.2 (43.0-61.4) 1.2 (0.7-2.0) 0.8 (0.4-1.5) 0.58
Left vs. right Arkader, 2007 60.0 (29.6-90.4) 30.0 (1.6-58.4) 0.9 (0.4-1.6) 1.3 (0.4-4.5) 1.00
Bilateral
Bilateral vs. unilateral Schwend, 2000 7.7 (0.0-22.2) 98.4 (96.2-100.0) 4.8 (0.5-49.9) 0.9 (0.8-1.1) 0.26
a
Computed using two-sided Fisher

s exact test.
P
-values of 0.05 or less were considered statistically significant and are presented in bold text.
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distal metaphyseal femur fractures may indicate in-
creased likelihood of abuse.
This review has three principal limitations. First, the stud-
ies were mostly retrospective
in design and not all subjects
were assessed consistently for clinical findings, potentially
contributing to detection bias. Second, as there is no clear
gold standard for diagnosing c
hild abuse, there is concern
for circular reasoning in the identification of factors associ-
ated with increased risk of abuse. Third, influence of the
abuse determination method on
abuse prevalence estimates
was evident: studies employin
g more stringent criteria for
making a determination of abuse reported lower abuse
rates than studies with less stringent criteria. This obser-
vation is highlighted in a study where 38% of cases were
reported to CPS for suspected abuse, but only 2% were
confirmed secondary to abuse at court hearings [22]. An-
other key concern lies in the potential differences across
physicians in calibration of their determinations of abuse
[38,39]. As a result, the variability of findings of abuse
might reflect the spectrum of criteria for those determina-
tions, rather than an underlying variation in the preva-
lence of abuse if all studies applied the same criteria for
determining abusive fractures.
The results of this review underscore the need for pro-
spective studies of children with femur fractures to allow
for more accurate estimation of abuse risk in this popula-
tion. In such studies, standardized evaluation and data
collection procedures would be utilized to minimize
detection bias and circular reasoning. Lacking a gold
standard method for deter
mining abuse, these ideal
studies would report whether abuse was diagnosed using
specific stated case criteria, as well as whether abuse was
confirmed by CPS or court proceedings.
Conclusions
This comprehensive literatur
e review underscores the high
prevalence of abuse among ch
ildren <12 months old with
femur fractures. In addition, non-ambulatory status, a sus-
picious history, and the presence of additional injuries were
associated with increased likelihood of abusive femur
fracture in multiple studies. No significant association
was found between probability of determination of abuse
and the following characteristics: fracture side; spiral frac-
ture type; bilateral fractures. Additional prospective stud-
ies are needed to further elucidate the characteristics that
affect abuse probability in children with femur fractures.
Additional files
Additional file 1:
Search Terms.
Terms used for performing searches in
the PubMed/MEDLINE database. Studies with a publication type of

case
report

were excluded. An almost identical set of terms was used for


searches in the CINAHL database.
Additional file 2:
PRISMA Checklist.
From:
Moher D, Liberati A, Tetzlaff
J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for
Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med
6(6): e1000097.
Abbreviations
cps:
Child protective services; mvc: Motor vehicle crash.
Competing interests
The authors do not have conflicts of interest to disclose.
Authors

contributions
JW conceived of the systematic review and participated in design of the
review, development of the search strategy, screening and assessment of
articles, data abstraction, statistical analysis and manuscript drafting. OF
participated in design of the review, development of the search strategy,
screening and assessment of articles, data abstraction, statistical analysis, and
manuscript drafting. VM participated in design of the review, screening and
assessment of articles and manuscript editing. RL participated in design of
the review, statistical analysis and manuscript editing. CF and DR participated
in design of the review and manuscript editing. All authors read and
approved the final manuscript.
Acknowledgements
We would like to acknowledge Maria de Fatima Reyes for her assistance with
identification and screening of abstracts of studies obtained from search
databases.
Financial disclosure
This review was funded in part by grant 1K23HD071967-01from the National
Institute of Child Health and Human Development (NICHD). Dr. Joanne
Wood

s institution has received payment for expert witness court testimony


that Dr. Wood has provided in cases of suspected child abuse.
Author details
1
Division of General Pediatrics and PolicyLab, The Children

sHospitalof
Philadelphia, 3535 Market Street, Floor 15, Philadelphia PA19104, Pennsylvania.
2
Leonard Davis Institute of Health Economics, Colonial Penn Center, 3641
Locust Walk, Philadelphia 19104, Pennsylvania.
3
Department of Pediatrics,
Perelman School of Medicine at the University of Pennsylvania, Philadelphia
19104, Pennsylvania.
4
Department of Biostatistics and Epidemiology, Perelman
School of Medicine at the University of Pennsylvania, Philadelphia 19104,
Pennsylvania.
Received: 15 January 2014 Accepted: 19 June 2014
Published: 2 July 2014
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doi:10.1186/1471-2431-14-169
Cite this article as:
Wood
et al.
:
Prevalence of abuse among young
children with femur fractures: a systematic review.
BMC Pediatrics
2014
14
:169.
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et al. BMC Pediatrics
2014,
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:169
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