Intracranial Injury Among Children with Abuse-Related Long Bone Fractures

BACKGROUND: Intracranial injury (ICI) from abusive head trauma is the leading cause of death among young abused children but is difficult to detect. Long bone fracture (LBF) may lead to the recognition of abuse in young abused children. OBJECTIVES: This study is the first to report the incidence and features of ICI in children with abuse and LBFs. METHODS: This is a retrospective study of children younger than 3 years with the diagnosis of LBF in the National Trauma Data Bank from 2009 to 2014. LBF, abuse, and clinical features were identified using International Classification of Diseases, Ninth Revision codes. Abuse-related LBF with and without ICI were compared to identify risk factors for ICI. RESULTS: There were 4345 encounters for abuse-related LBF in kids ages < 3 years; 970 (22%) had ICI. Infants < 1 year of age were more likely to have ICI compared with older children (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.38–2.33). After adjusting for age, fracture of the ulna, radius, tibia, or fibula were associated with greater odds of ICI (OR 3.35, 95% CI 2.81–4.00). Abuse-related LBF with additional findings of skull fracture, rib fracture, or head/neck bruising had an increased odds of ICI (OR 8.27, 95% CI 6.85–9.98; OR 2.67, 95% CI 2.28–3.14; OR 2.41, 95% CI 1.99–2.92, respectively). CONCLUSIONS: ICI occurred in nearly 1 in 4 children under 3 years old with abuse-related LBF. Abuse-related LBF with skull fracture, rib fracture, head/neck bruising, or patient age < 1 year should prompt consideration for ICI with head imaging.