Mary Clyde Pierce

Bruising characteristics discriminating physical child abuse from accidental trauma.

OBJECTIVE: Our objective was to conduct a pilot study to identify discriminating bruising characteristics and to model those findings into a decision tool for screening children at high risk for abuse. METHODS: A case-control study of children 0 to 48 months of age who were admitted to a PICU because of trauma was performed. Case subjects (N = 42) were victims of physical abuse, and control subjects (N = 53) were children admitted because of accidental trauma during the same time period. Bruising characteristics (total number and body region) and patient age were compared for children with abusive versus accidental trauma. The development of a decision rule for predicting abusive trauma was accomplished with the fitting of a classification and regression tree through binary recursive partitioning. RESULTS: Ninety-five patients were studied. Seventy-one (33 of 42 patients in the abuse group and 38 of 53 in the accident group) were found to have bruising, and the characteristics were modeled. Characteristics predictive of abuse were bruising on the torso, ear, or neck for a child ≤4 years of age and bruising in any region for an infant <4 months of age. A bruising clinical decision rule was derived, with a sensitivity of 97% and a specificity of 84% for predicting abuse. CONCLUSIONS: Discriminating differences exist in bruising characteristics for abusive versus accidental trauma. The body region- and age-based bruising clinical decision rule model functions as a clinically sensible screening tool to identify young children who require further evaluation for abuse.

Serum S100B Concentrations Are Increased after Closed Head Injury in Children: A Preliminary Study

Traumatic brain injury (TBI) is a leading cause of death and disability in children. The current gold standards for diagnosis of TBI after closed head injury (CHI) have limitations, particularly in cases of inflicted injury. S100B is a protein that is specific to astrocytes. Serum S100B concentrations are increased in adults after CHI; there are no studies of serum S100B after CHI in children. The goal of this study was to measure the serum concentrations of S100B in children inflicted and noninflicted mild, moderate, and severe CHI. CHI severity was defined by initial Glasgow Coma Scale score. Forty-five children aged 0-13 years with mild (n = 27), moderate (n = 6), and severe (n = 12) CHI were enrolled prospectively. Blood was obtained as soon as possible after injury (range: 0.5-15.25 h) and every 12 h for up to 5 days when vascular access was available. Single control samples were obtained from 16 children aged 0-11 years with isolated long-bone fractures. Twenty-two patients (49%), including both patients with inflicted CHI, had an abnormal initial serum S100B concentration where an abnormal concentration was defined as greater than mean control concentration plus two standard deviations. S100B was detectable more than 12 h after injury only in patients with severe CHI. We conclude that serum S100B is increased in almost half of children after mild, moderate, and severe inflicted and noninflicted CHI. The increase is transient, lasting less than 12 h after injury, except in children with severe injury. Future research will focus on the possibility of using serum S100B as a screening test for inflicted CHI.

The Anatomic Relationship of Femoral Vein to Femoral Artery in Euvolemic Pediatric Patients by Ultrasonography: Implications for Pediatric Femoral Central Venous Access

BACKGROUND Knowledge of the femoral vein (FV) anatomy in pediatric patients is important in the selection of appropriate size central line catheters as well as the approach to central venous access. This knowledge may avoid potential complications during central line access. OBJECTIVES To describe the relationship of the FV to the femoral artery (FA). To measure FV diameter and FV depth using ultrasonography (US) in newborns, infants, and children up to 9 years of age. METHODS This study was a prospective descriptive study at a tertiary care childrens hospital. A convenience sample of euvolemic children was enrolled aged 0-9 years presenting to an urban pediatric emergency department. All patients underwent a standardized US evaluation using a Sonosite Titan bedside machine by a single emergency physician. The FA and FV were identified by four criteria: relative positions, FV compressibility, FV enlargement by Valsalva maneuver, and absence of FV pulsatility. The position of the FV relative to the FA was described as being completely overlapped by the FA, having partial (<50%) overlap by the FA, and having no overlap by the FA. The FV depth was measured from the skin to the superior border of the vein using the US machines caliper function. RESULTS A total of 84 patients were studied. The FV was found to be completely overlapped by the FA in 8% of subjects and partially overlapped by the FA in 4% of subjects. The mean FV diameter ranged from 4.5 mm in young infants to 10.8 mm in patients 9 years of age. The mean FV depth ranged from 6.5 mm in neonates to 11.2 mm in patients 9 years of age. CONCLUSIONS External landmarks were not always predictive of internal anatomy. The FV was completely or partially overlapped by the FA in 12% of cases. Thus, visualization of femoral vessels should be recommended prior to attempting pediatric femoral central venous access.

Femur fractures resulting from stair falls among children: an injury plausibility model.

Background. Stair falls are common among young children and are also common false histories in cases of child abuse. When a child presents with a femur fracture and a stair-fall history, a judgment of plausibility must be made. A lack of objective injury and biomechanical data makes plausibility determination more difficult. Our objective was to characterize key features associated with femur fractures from reported stair falls, to develop a model for assessing injury plausibility (IP). Methods. Children 2 to 36 months of age who presented with a femur fracture from a reported stair fall were studied prospectively. Detailed history recording, examinations, fracture characterization, and injury scene analyses were conducted, and biomechanical measures associated with injury prediction were calculated. With our proposed IP model, all cases were then scored for the detail of history, biomechanical compatibility of fracture morphologic features, time to seeking care, and presence of other injuries. Results. Twenty-nine children were diagnosed with a femur fracture resulting from a reported stair fall. The IP model made a clear distinction between 2 groups, designated plausible and suspicious. Significant differences were observed for the detail of history, biomechanical compatibility of fracture, time to seeking care, presence of other injuries, and total IP scores. In the plausible group, the minimal linear momentum associated with a transverse fracture was almost 10-fold greater than that for spiral or buckle fracture types. Conclusions. This study adds new information to the current body of knowledge regarding injury biomechanics and fractures among children. The IP model provides an objective means of assessing plausibility of reported stair-fall–related femur fractures and identifies key characteristics to facilitate decision-making.

Influence of fall height and impact surface on biomechanics of feet-first free falls in children.

OBJECTIVE The objectives of our study were to assess biomechanics associated with feet-first free falls in 3-year-old children and to investigate the influence of impact surface type and fall height on key biomechanical measures associated with injury risk. METHODS Repeatable feet-first free fall experiments were conducted in a laboratory mock-up environment using an instrumented Hybrid II 3-year-old test dummy. Impact surface type and fall height were varied to examine their influence on biomechanical measures. RESULTS Feet-first falls from short distances (27 in.) (0.69 m) were found to have a low risk of contact-type head injury, regardless of impact surface type. When comparing different types of impact surfaces in a 27 in. (0.69 m) fall, head acceleration associated with falls onto playground foam was significantly less than that associated with falls onto wood, linoleum or padded carpet. For falls onto playground foam, femoral compressive loads and bending moments were found to significantly increase as fall height increased. CONCLUSIONS Impact surface type and fall height were found to influence biomechanics associated with injury risk in feet-first free falls as assessed through experimental mock-ups using an instrumented child test dummy. Feet-first falls from short distances (27 in.) (0.69 m) were associated with a low risk of contact-type head injury as assessed using HIC, irrespective of impact surface type.

Pediatric short-distance household falls: Biomechanics and associated injury severity

OBJECTIVES Short-distance household falls are a common occurrence in young children, but are also a common false history given by caretakers to conceal abusive trauma. The purpose of this study was to determine the severity of injuries that result from accidental short-distance household falls in children, and to investigate the association of fall environment and biomechanical measures with injury outcomes. METHODS Children aged 0-4 years who presented to the Emergency Department with a history of a short furniture fall were included in the study. Detailed case-based biomechanical assessments were performed using data collected through medical records, interviews, and fall scene investigations. Injuries were rated using the Abbreviated Injury Scale (AIS). Each case was reviewed by a child abuse expert; cases with a vague or inconsistent history and cases being actively investigated for child abuse were excluded. RESULTS 79 subjects were enrolled in the study; 15 had no injuries, 45 had minor (AIS 1) injuries, 17 had moderate (AIS 2) injuries, and 2 had serious (AIS 3) injuries. No subjects had injuries classified as AIS 4 or higher, and there were no fatalities. Children with moderate or serious injuries resulting from a short-distance household fall tended to have fallen from greater heights, have greater impact velocities, and have a lower body mass index than those with minor or no injuries. CONCLUSION Children aged 0-4 years involved in a short-distance household fall did not sustain severe or life-threatening injuries, and no children in this study had moderate or serious injuries to multiple body regions. Biomechanical measures were found to be associated with injury severity outcomes in short-distance household falls. Knowledge of relationships between biomechanical measures and injury outcomes can aid clinicians when assessing whether a childs injuries were the result of a short-distance fall or some other cause.

Spica cast application in the emergency room for select pediatric femur fractures.

Objectives: This study was designed to evaluate the efficacy and safety of immediate spica casting in the emergency room (ER) and evaluate the effect of discharge from the emergency room on short- term complications. Design: Retrospective review of patients treated with immediate spica casting in the ER between June 1, 1993 and July 30, 2001. Setting: Major, pediatric, orthopaedic trauma and referral center. Patients: A total of 145 pediatric femur fractures in children, younger than age 7 years, treated with immediate spica casting in the ER were reviewed to determine radiographic outcome and short-term complication rates. Intervention: All patients underwent immediate spica cast placement in the ER under conscious sedation. Patients meeting specific criteria were discharged immediately from the ER. Main Outcome Measurements: Radiographic acceptability of alignment at fracture union (angulation, shortening), loss of reduction, number of return visits to the emergency room, and clinical outcome at final follow-up. Results: Average follow-up was 20 ± 16 weeks (range, 1-9 months). Forty-eight patients (33%) were discharged from the ER. No clinical complications were noted at last follow-up. All children younger than age 2 years, and 86.5% of children ages 2 to 5 years, met acceptable malalignment parameters on final radiographs. There were 16 ER visits (11%) for cast problems. Rereduction in the operating room was needed in 11 patients (8.9%); 6.9% of patients had a cast problem noted during follow-up visits. Only 9% of patients developed a major complication. Initial shortening was the only independent risk factor found to be associated with loss of reduction. Admission status had no significant effect on the number of ER visits or development of a complication. Conclusions: If there are no associated factors requiring admission (ie, child abuse or polytrauma), spica casting in the ER for pediatric femur fractures followed by immediate discharge can be safely performed with a low complication rate in children younger than age 6 years, nearly eliminating the need for general anesthesia.

Bruising in infants: those with a bruise may be abused.

Bruising in the young infant is rare, and if present, this may be a manifestation of physical child abuse. Early signs of abuse, such as bruising, are often overlooked or their significance goes unrecognized resulting in poor patient outcomes. In such cases, the opportunity to intervene and potentially prevent repeat injury is lost, and the child is placed back in harms way. This brief report presents 3 cases of nonmobile infants who presented to health care providers with bruising before a subsequent fatal or near-fatal event. These cases emphasize the importance of including abusive trauma in the differential diagnosis of an infant with a bruise or a history of easy bruising and the importance of initiating a thorough trauma evaluation immediately and concomitantly with any other workup for the causes of bruising in the noncruising infant.

Psychiatric patients in the pediatric emergency department undergoing routine urine toxicology screens for medical clearance: Results and use

Objective: We sought to determine the use and results of urine toxicology screens (UTS) in psychiatric patients undergoing a UTS test for medical clearance in a pediatric emergency department. Methods: A structured retrospective study was conducted over a 6-month period. All emergency department (ED) charts were reviewed of patients 8 to 17 years who had a UTS. Urine toxicology screens were identified as medically indicated or routine-driven. Medically indicated UTS were patients who presented with seizures, syncope, headache, altered mental status, ingestion, chest pain/palpitation, shortness of breath, sexual assault, or those who were brought in for motor vehicle accident (MVA). Routine-driven UTS were uncomplicated psychiatric patients who presented with aggressive or out of control behavior, intentional self-inflicted wounds, or symptoms of depression, all of whom presented without any evidence of drug or alcohol ingestion or altered mental status. Routine-driven UTS were quantified for positive tests. In addition, we determined the change in management and disposition of those patients. We also determined the concordance of provided drug use history with UTS result. Results: Of the 652 charts reviewed, 267 UTS were medically indicated; 385 were routine-driven. Of the routine-driven UTS group, 254/267 (95%) patients with negative screens and 115/118 (97%) with positive screens were referred for psychiatric treatment after psychiatric evaluation. Fisher exact test of the comparison of the disposition after psychiatric assessment with the UTS result was nonsignificant. The UTS result also had no effect on the type of psychiatric disposition (ie, outpatient therapy, partial hospitalization, inpatient hospitalization). Concordance with provided history of illicit drug use was significant. Conclusions: Routine-driven UTS in uncomplicated pediatric psychiatric patients being evaluated in the ED offered little additional information, did not influence management, and potentially increased both ED cost and time. Patients with straightforward psychiatric complaints may be medically cleared without a UTS.

Biomechanical evaluation of dual-energy X-ray absorptiometry for predicting fracture loads of the infant femur for injury investigation : An In vitro porcine model

OBJECTIVE The purpose of this study was to determine the ability of bone mineral density (BMD) measured by dual-energy x-ray absorptiometry (DXA) and geometry measured by biplanar x-ray to predict fracture mechanics in vitro in an immature femur model. DESIGN Prospective analysis of radiographic and biomechanical data was performed. SETTING In vitro experimentation. INTERVENTIONS Bone geometry and DXA data were obtained before mechanical testing. Twenty-two porcine femora from males and females (age 3 to 12 months; body weight 3.6 to 7.0 kilograms) were fractured. Mechanical tests were performed on the diaphysis of the femora in two loading configurations: (a) three-point bending to simulate loads that result in transverse fractures; and (b) torsion to simulate twisting injuries that result in spiral fractures. MAIN OUTCOME MEASURES Correlation of radiographic data with the experimentally determined bone strength. RESULTS Three-point bending consistently resulted in transverse fractures. Femoral diaphysis BMD (mean, 0.304 grams per square centimeter; SD, 0.028 grams per square centimeter) strongly correlated (r2 = 0.938) to fracture load in bending. Load at failure ranged from 530 to 1,024 N (mean, 726 N; SD, 138 N), consistent with the findings of Miltner. Empirically derived strength parameters coupling BMD with geometry accurately predicted bending loads (r2 = 0.84, p < 0.001) and energy to failure (r2 = 0.88, p < 0.05). Torsional loading failed to generate spiral fractures consistently, resulting in either end plate or diaphyseal fractures. Load at failure for torsion ranged from 1,383 to 3,559 Newton-millimeters (mean, 2,703 Newton-millimeters; SD, 826 Newton-millimeters). Because of these inconsistent fracture results, empirical strength parameters for torsion could not be derived. CONCLUSION BMD coupled with geometry is a strong predictor of bending fracture loads in the immature femoral diaphysis. A similar relationship could not be shown for torsion because of inconsistent failure results. This study represents an initial attempt at developing a methodology for predicting the strength of young bones from radiographic measures. Further research is required to establish this methodology and to show the necessary correlation with immature human bone.