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Predictors for Nonaccidental Trauma in a Child With a Fracture—A National Inpatient Database Study

Zhao, Caixia MD; Starke, Matthew MD; Tompson, Jeffrey D. MD; Sabharwal, Sanjeev MD, MPH

JAAOS - Journal of the American Academy of Orthopaedic Surgeons: June 11, 2019 - Volume Publish Ahead of Print - Issue - p
doi: 10.5435/JAAOS-D-18-00502
Research Article: PDF Only

Background: Despite heightened awareness and multidisciplinary efforts, a predictive model to help the clinician quantify the likelihood of nonaccidental trauma (NAT) in a child presenting with a fracture does not exist. The purpose of this study was to develop an evidence-based likelihood of NAT in a child presenting with a fracture.

Methods: Using the 2012 Kids' Inpatient Database, we identified all available pediatric inpatients admitted with an extremity or spine fracture. Children with a fracture were subcategorized based on the diagnosis of NAT. Multivariate analysis using multiple logistic regression was used to generate odds ratios and create a predictive model for the probability of NAT in a child with a fracture.

Results: Of the 57,183 pediatric fracture cases, 881 (1.54%) had a concurrent diagnosis of NAT. Of these children, those presenting with multiple fractures had the highest rate of NAT (2.8%). The overall mortality rate in patients presenting with fractures and abuse was 1.8%, which was twice as high as patients without abuse (odds ratio [OR] = 2.0). Based on multivariate analysis, younger age (OR = 0.5), black race (OR = 1.7), intracranial injury (OR = 3.7), concomitant rib fracture (OR = 7.2), and burns (OR = 8.3) were positive predictors of NAT in a child with a fracture. A weighted equation using regression coefficients was generated and plotted on a receiver operative characteristic curve, demonstrating excellent correlation and probability of NAT (area under curve = 0.962). (Equation – ln (P/(1 − P)) = −1.79 to 0.65 (age in years) + 0.51 (black race) + 1.97 (rib fracture) + 1.31 (intracranial injury) + 2.12 (burn)).

Conclusion: Using a large, national inpatient database, we identified an overall prevalence of 1.54% of NAT in children admitted to the hospital with a fracture. Based on five independent predictors of NAT, we generated an estimated probability chart that can be used in the clinical workup of a child with a fracture and possible NAT. This evidence-based algorithm needs to be validated in clinical practice.

Level of Evidence: Prognostic study, Level III (case-control study).

From the Rutgers-New Jersey Medical School, Newark, NJ (Dr. Zhao, Dr. Starke, and Dr. Tompson), and the Department of Clinical Orthopedics, University of California, San Francisco, Benioff Children's Hospital of Oakland, Oakland, CA (Dr. Sabharwal).

Correspondence to Dr. Sabharwal:

None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Zhao, Dr. Starke, Dr. Tompson, and Dr. Sabharwal.

© 2019 by American Academy of Orthopaedic Surgeons
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