Victims Of Nonaccidental Trauma Research Articles

Nonaccidental Trauma in Pediatric Elbow Fractures: When You Should Be Worried.

Nonaccidental trauma (NAT) is a rising source of morbidity and mortality in the pediatric population. Fractures are often the first cause for presentation to health care providers in the case of NAT but can be misidentified as accidental. Given that elbow fractures are the most common accidental injuries among pediatric patients, they are not traditionally associated with NAT. This study aims to determine the prevalence of NAT among elbow fractures and identify common features in nonaccidental elbow fractures. Current Procedural Terminology (CPT) codes were used to retrospectively identify all pediatric (0 to 17) elbow fractures at a single, tertiary children's hospital between 2007 and 2017. Among these, all fractures for which an institutional child abuse evaluation team was consulted were identified. The medical record was then used to determine which of these fractures were due to NAT. Standard injury radiographs of all victims of NAT as well as all patients under 1 year of age were blinded and radiographically evaluated for fracture type by a pediatric orthopaedic surgeon. The prevalence of nonaccidental elbow fractures across the 10-year study period was 0.4% (N=18). However, the prevalence of nonaccidental elbow fractures in those patients below 1 year of age was markedly higher at 30.3% (10/33). Among all elbow fractures in patients below 1 year of age, supracondylar humerus fractures were the most common fracture type (19/33, 57.6%), yet transphyseal fractures (6/33, 18.1%) were most commonly the result of NAT (5/6, 83.3%). In children over 1 year of age, fracture type was not an indicator of NAT. The vast majority of pediatric elbow fractures (99.6%) are accidental. However, certain factors, namely age below 1 year and transphyseal fractures increase the likelihood that these fractures may be a result of NAT. Level IV: retrospective case series.

Did the COVID-19 pandemic lead to increased pediatric musculoskeletal nonaccidental trauma? A cross-sectional study.

Lockdowns due to COVID-19 increased known risk factors for nonaccidental trauma (NAT), including economic instability and parental stress. We sought to evaluate potential changes in the frequency and types of fractures associated with NAT during the COVID-19 pandemic. A retrospective cross-sectional study was conducted using de-identified data obtained from the IBM Watson Health Explorys Cohort Discovery database. Systematized Nomenclature of Medicine-Clinical Terms were used to query the database for victims of NAT in 2019 and 2020. Within this cohort of patients, we then identified those who were also diagnosed with a fracture within 21 days of the NAT event. Demographic data were compared between 2019 and 2020 where possible using chi-squared testing, and relative risks for various fracture diagnoses were calculated with 95% confidence intervals. There were 9500 records overall of pediatric NAT in 2019 compared to 9350 in 2020. Of those, in 2019 550 were associated with a diagnosis of fracture versus 570 in 2020. The relative risk of fracture due to NAT in 2020 when compared to 2019 was not significantly higher [relative risk, 1.05 (95% confidence interval, 0.94-1.17)]. The relative risk for each category of fracture diagnosis in 2020 was slightly higher, but not to a statistically significant degree. Despite increasing known risk factors, the frequency of NAT remained unchanged as the result of the COVID-19 pandemic. We also did not identify significant changes in the risk of fracture due to NAT, nor any changes in the associated types of fractures.

Cervical Spine Clearance in the Pediatric Trauma Patient

In this review, we examine the current evidence-based practices in cervical spine evaluation and imaging in injured children, with an emphasis on criteria for cervical collar removal. The primary goal of this review is to synthesize an algorithm for cervical spine clearance using the best available evidence. Removal of the cervical collar without imaging is appropriate for most asymptomatic patients that are conscious and neurologically intact. Patients with negative imaging and persistent neck pain can be safely discharged home in a cervical collar with outpatient follow-up. High-resolution computed tomography (CT) of the cervical spine is superior to plain films in ruling out cervical spine injury and approaches the sensitivity of magnetic resonance imaging (MRI). Suspected or confirmed victims of nonaccidental trauma should undergo MRI of the cervical spine, as it may aid in confirming the mechanism of injury and identify non-bony injuries that would otherwise go unnoticed. Most pediatric trauma patients do not require advanced imaging (CT or MRI) to clear the cervical spine. A period of observation and cervical collar stabilization is appropriate for most patients without overt evidence of severe cervical spine trauma. Interval re-examination may be performed, as many patients will have resolution of pain and can then be cleared clinically without advanced cross-sectional imaging. When advanced imaging is sought, spine specialist consultation is recommended.

Non-accidental trauma increases length of stay and mortality in pediatric trauma.

More than half a million children experience non-accidental trauma (NAT) annually. Historically, NAT has been associated with an increased hospital length of stay (LOS). We hypothesized that in pediatric trauma patients, NAT is associated with longer hospital LOS, independent of injury severity, compared to accidental trauma (AT). The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients aged 1-16years. Patients were stratified into two groups: AT and NAT. The median LOS for the entire cohort was identified and used in a multivariable logistic regression analysis. From 93,089 pediatric trauma patients, 417 (< 0.1%) were involved in NAT. Patients with NAT had a lower median age (3 vs. 9years, p < 0.001) and higher median injury severity score (10 vs. 5, p < 0.001), compared to patients with AT. After controlling for covariates, patients with NAT were associated with a longer hospital LOS (≥ 2days), compared to those with AT (OR = 4.99 CI = 3.55-7.01, p < 0.001). In comparison to AT, NAT was also associated with a higher mortality rate (10.3% vs. 0.8%, p < 0.001). Pediatric patients presenting after NAT have a prolonged hospital and ICU LOS, even after adjusting for injury severity. Furthermore, pediatric victims of NAT had a higher mortality rate compared to those presenting after AT.

Understanding non-accidental trauma in the United States: A national trauma databank study

BackgroundThe purpose of this study is to characterize the epidemiology, injury patterns, outcomes and trends of non-accidental trauma (NAT) in the United States using a large national database. MethodsChildren <15 years presenting after NAT were identified in the 2007-2014 National Trauma Databank research datasets. Clinical and outcome data were analyzed using descriptive statistics, chi-square and logistic regression. ResultsOf 678,503 children admitted for traumatic injuries, 3% (19,149) were victims of NAT. The majority (95%) were under 5 years and 71% under 1 year old. The majority (59%) were male. The median injury severity score (ISS) was 10 (IQR:5-19). African Americans were disproportionally affected (27% vs 17% of all traumas), and the majority had public or no insurance (85%). Incidence was highest in the midwest and lowest in the northeast regions of the country, although trends varied over time. NAT resulted in 43% of trauma deaths in children <1 year and 31% of trauma deaths in children <5. Traumatic brain injury (TBI) was the most commonly encountered diagnosis (50%). Polytrauma was common, and certain injury patterns were identified. Urgent operation was required in 6%, 43% were admitted to intensive care, and 9% died. Mortality was independently associated with TBI, thoracic injury, hollow viscus injury and older age. ConclusionNon-accidental trauma is a leading cause of trauma mortality in young children. Multiple injuries are common, requiring comprehensive evaluation and early surgical involvement. The data presented in this study could serve as a guide to target injury prevention efforts. Level of evidenceIII Study typePrognostic and Epidemiological

Consistent screening of admitted infants with head injuries reveals high rate of nonaccidental trauma

PurposeImplementation of a nonaccidental trauma (NAT) screening guideline for the evaluation of infants admitted with an unwitnessed head injury has eliminated screening disparities. This study sought to determine the overall NAT rate and key predictive factors using this guideline. MethodsAll infants screened via the guideline from 2008 to 2015 were retrospectively reviewed. The overall rate of NAT as determined by our child abuse team was determined. In addition, a logistic regression model was developed to evaluate potential predictors of increased risk of NAT. ResultsA total of 563 infants were screened with an overall rate of NAT of 25.6% (n=144). NAT screening was consistent across race and insurance status. By univariate analysis, patients with government insurance or no insurance had a significantly higher rate of NAT, but race was not a factor. Also NAT victims had significantly higher ISS. Skeletal survey showed high positive predictive value of 94%. When regression modeling was performed, ISS, abnormal skeletal survey and having public or no insurance were significantly correlated with NAT, while race showed no correlation. ConclusionOne quarter of infants admitted with a head injury not witnessed in a public situation were identified as the victims of NAT. The high rate of abuse among this population supports routine screening in order to avoid missing intentional injuries and preventing future injuries. Race is not a predictor of NAT, but insurance status, as a proxy for socioeconomic status, is correlated, and further investigation is needed. Level of evidenceIII

Pediatric abdominal injury patterns caused by “falls”: A comparison between nonaccidental and accidental trauma

Background/PurposeFalling from a low height is the most common history given by caregivers of pediatric nonaccidental trauma (NAT) victims evaluated for blunt abdominal trauma (BAT). The purpose of this study is to compare the patterns of injuries seen in children with BAT who are victims of NAT with those seen after a fall-related incident. MethodsTrauma database query from regional pediatric trauma centers identified patients were who were evaluated for BAT resulting from either NAT or a fall. Study groups included patients younger than five years who were (1) victims or NAT, or (2) fall casualties. ResultsSixty-five NATs and 115 fall casualties were identified. NAT victims had higher ISS, had more severe head injuries according to AIS scores, had more hollow viscus injuries, and had more pancreatic injuries. Fall casualties were more likely to have solid organ injuries. ConclusionsWhen evaluating children with a history of blunt abdominal trauma caused by a fall, suspicion for NAT is warranted if the child is younger than five years, has a hollow viscus, pancreatic, and/or severe head injury and has a high ISS. Likewise, isolated splenic or renal injury allays suspicion for NAT.

Role of the surgeon in non-accidental trauma.

Non-accidental trauma (NAT) represents a significant cause of morbidity and mortality in the pediatric population. The management of these patients often involves many care providers including the surgeon. Victims of NAT often present with multiple injuries and as such should be treated as trauma patients with complete trauma evaluation including primary, secondary and tertiary surveys. Common injury patterns in NAT include extremity fractures, closed head injury and intra-abdominal injury. Brain imaging is of importance to rule out acute or sub-acute intracranial hemorrhage. Children under the age of 5years with acute intracranial pathology should also be evaluated by an ophthalmologist to rule out retinal hemorrhages, which are considered pathognomonic for child abuse from violent shaking. In instances when abdominal injury is suspected, prompt evaluation by a surgeon is recommended along with CT imaging. Finding of extremity fractures should prompt evaluation by an orthopedic surgeon. At our institution, all patients with suspected NAT are admitted to the pediatric surgery service for complete evaluation and management. We encourage other pediatric trauma centers to employ a similar approach so that these complicated patients are managed safely and effectively.

Risk factors for recurrent injuries in victims of suspected non-accidental trauma: a retrospective cohort study.

BackgroundMany children who are victims of non-accidental trauma (NAT) may be repeatedly evaluated for injuries related to maltreatment. The purpose of this study was to identify risk factors for repeated injuries in children with suspected NAT.MethodsWe conducted a retrospective cohort study using claims data from a pediatric Medicaid accountable care organization. Children with birth claims and at least one non-birth related claim indicating a diagnosis of NAT or skeletal survey in 2007–2011 were included. Recurrent events were defined as independent episodes of care involving an urgent/emergent care setting that included a diagnosis code specific for child abuse, a CPT code for a skeletal survey, or a diagnosis code for an injury suspicious for abuse. Cox proportional hazards models were used to examine risk factors for recurrent events.ResultsOf the 1,361 children with suspected NAT, a recurrent NAT event occurred in 26% within 1 year and 40% within 2 years of their initial event. Independent risk factors for a recurrent NAT event included a rural residence, age < 30 months old, having only 1 or 2 initially detected injuries, and having a dislocation, open wound, or superficial injury at the previous event (p ≤ 0.01 for all).ConclusionsOver 25% of children who experienced a suspected NAT event had a recurrent episode within one year. These children were younger and more likely to present with “minor” injuries at their previous event.

Increased morbidity and mortality of traumatic brain injury in victims of nonaccidental trauma

The purpose of this study was to determine if the morbidity and mortality associated with traumatic brain injury (TBI) are worse in children who experienced nonaccidental trauma (NAT) compared with TBI from other traumatic mechanisms. We identified all pediatric patients admitted with the diagnosis of TBI between 2001 and 2010 in our institutional trauma registry with an Abbreviated Injury Scale (AIS) score greater than 1. Patients were divided into groups based on a nonaccidental (NAT) or accidental mechanism of injury. Need for gastrostomy tube insertion was used as a marker of more severe neurologic morbidity in survivors of TBI. Group comparisons were made using Fisher's exact tests. A total of 2,782 patients with TBI were included; 315 (11.3%) patients had TBI secondary to NAT. Overall mortality and AIS-specific mortality were higher in patients with TBI secondary to NAT. In comparison with patients with TBI secondary to accidental mechanisms, patients with TBI secondary to NAT were younger (mean, 1 year vs. 8 years), had longer intensive care unit stays (mean, 3 days vs. 1 day), and required gastrostomy tubes more often (6% vs. 1%, p < 0.0001). Even among the subgroup of patients with severe TBI, (AIS score 4 and 5), patients with NAT required gastrostomy tubes more often (5% vs. 2%, p = 0.014). Patients with TBI from NAT have increased morbidity and mortality compared with patients with TBI from accidental mechanisms; these differences are present at all levels of severity of injury. Patients with TBI from NAT represent a vulnerable group of pediatric trauma patients who are at increased risk for death and worse outcome and who will require greater short- and long-term medical resources.

Prognosis for Children in Cardiac Arrest Shortly After Blunt Cranial Trauma

The goal of this investigation is to determine the success rate of aggressive cardiorespiratory resuscitation in children who experience blunt cranial trauma of sufficient magnitude to quickly cause cardiac arrest. The records of all the children who, within a 6-year period, suffered cardiac arrest at the scene of injury, during transport or in the emergency department of a level one pediatric trauma center, as a consequence of blunt cranial trauma, form the basis of this study. One of the 40 children who met the inclusion criteria survived. Their ages ranged from 1 month to 16 years, and all had a Glasgow Coma Score of 3 at the scene of injury. Forty-two percent were passengers in motor vehicles, and 32% were victims of nonaccidental trauma. Eleven of the 17 children in the motor vehicle crash were not properly restrained. Eleven of the unrestrained children plus two who were properly restrained were ejected at the time of impact. The average cardiopulmonary resuscitation time was 36 (2-107) minutes. A sinus rhythm was established in 50% but was not sustained in most. The sole survivor was an 8-year-old boy who was ejected and had asystole at the scene. At discharge, he was walking well but had cranial nerve deficits and learning disability. Survival in 40 consecutive children with documented cardiac arrest caused by blunt cranial trauma was 2.5%. This series, when combined with other published reports, is supportive of the position that aggressive resuscitation is rarely successful after 10 minutes and futile after 20 minutes.

Comparison of accidental and nonaccidental traumatic brain injuries in infants and toddlers: demographics, neurosurgical interventions, and outcomes

Nonaccidental trauma has become a leading cause of death in infants and toddlers. Compared with children suffering from accidental trauma, many children with nonaccidental trauma present with injuries requiring neurosurgical management and operative interventions. A retrospective review was performed concerning the clinical and radiological findings, need for neurosurgical intervention, and outcomes in infants and toddlers with head injuries who presented to Albany Medical Center between 1999 and 2007. The Fisher exact probability test and ORs were computed for Glasgow Coma Scale (GCS) scores, hyperdense versus hypodense subdural collections, and discharge and follow-up King's Outcome Scale for Childhood Head Injury (KOSCHI) scores. There were 218 patients, among whom 164 had sustained accidental trauma, and 54 had sustained nonaccidental trauma (NAT). The patients with accidental traumatic injuries were more likely to present with GCS scores of 13-15 (OR 6.95), and the patients with NATs with of GCS scores 9-12 (OR 6.83) and 3-8 (OR 2.99). Skull fractures were present in 57.2% of accidentally injured patients at presentation, and 15% had subdural collections. Skull fractures were present in 30% of nonaccidentally injured patients, and subdural collections in 52%. Patients with evidence of hypodense subdural collections were significantly more likely to be in the NAT group (OR 20.56). Patients with NAT injuries were also much more likely to require neurosurgical operative intervention. Patients with accidental trauma were more likely to have a KOSCHI score of 5 at discharge and follow-up (ORs 6.48 and 4.58), while patients with NAT had KOSCHI scores of 3a, 3b, 4a, and 4b at discharge (ORs 6.48, 5.47, 2.44, and 3.62, respectively), and 3b and 4a at follow-up. Infant and toddler victims of NAT have significantly worse injuries and outcomes than those whose trauma was accidental. In the authors' experience, however, with aggressive intervention, many of these patients can make significant neurological improvements at subsequent follow-up visits.

Eliminating disparity in evaluation for abuse in infants with head injury: use of a screening guideline

Purpose Minority and disadvantaged children are evaluated for nonaccidental trauma (NAT) at higher rates than other children. At our institution, we implemented a guideline to perform skeletal surveys to screen for occult fractures in all infants with unwitnessed head injury (UHI). The goal was to determine if this guideline decreased disparities in the screening of African American (AA) and uninsured children. Patients and Methods For 54 months, rates of skeletal surveillance and abuse determination were compared between AA and white infants admitted with UHI before and after implementation of our guideline. Logistic regression was used to control for confounders. Results Before the guideline, AAs underwent skeletal surveillance more than whites (n = 208; 90.5% vs 69.3%; P = .01), with 20% of screened infants determined to be probable victims of NAT. Whites with private insurance were less likely to be screened compared to those without private insurance (50.0% vs 88.1%; P < .001). After the guideline, AA and whites were surveyed equally (n = 52; 92.3% vs 84.6%; P = 1.0), with 22% found to be probable cases of NAT. Conclusions This is the first report of a successful policy-based intervention to decrease disparity in care. The maintenance of a stable rate of NAT determination despite increased screening suggests more victims of abuse may be identified with guideline use, and therefore, this may be an additional benefit of the guideline.

Rare retinal haemorrhages in translational accidental head trauma in children

The characteristic findings in accidental head injury consist of linear skull fracture, epidural haematoma, localized subdural haematoma, or cortical contusion because of a linear or translational impact force. Retinal haemorrhages have been found, although uncommon, in accidental head trauma. We performed a retrospective study of 24 consecutive cases of children with severe head injuries caused by falls. Inclusion criteria were skull fractures and/or intracranial haemorrhages documented by computerized tomography. All patients underwent a careful ophthalmic examination including dilated indirect fundoscopy within the first 48 h following admission. No retinal haemorrhages could be found in patients whose accidents were plausible and physical and imaging findings were compatible with reported histories. Excessive bilateral retinal haemorrhages were found in only three children with the typical signs of shaken baby syndrome. In eight children, trauma had led to orbital roof fractures. Retinal haemorrhages were not found in any of the patients with accidental trauma despite the severity of their head injuries. Hence, we add more evidence that there are strong differences between the ocular involvement in accidental translational trauma and those in victims of non-accidental trauma. Fall-related injuries carry a very low risk of retinal haemorrhages.

Clues That Aid in the Diagnosis of Nonaccidental Trauma Presenting as an Apparent Life-Threatening Event

Apparent life-threatening events (ALTEs) can encompass many different diagnoses. Nonaccidental trauma (NAT) is one potential serious diagnosis. (1) To identify key elements in the history and physical exam in infants presenting with an ALTE that aid in the subsequent diagnosis of NAT; and (2) to evaluate the role of diagnostic studies in these infants in confirming the diagnosis of NAT. A retrospective chart review analysis, over a 2-year period, of infants with an ALTE was performed. From this group, all children with a discharge diagnosis of child physical abuse, shaken infant syndrome, or NAT were included in the study. 4 patients were found to be victims of NAT based on their clinical histories and physical examinations. Although confirmatory, ophthalmologic exams, skeletal surveys, and head CT scans had a lower sensitivity for NAT. NAT should be considered when an infant is admitted for evaluation of an ALTE.

PR_049: Utility of the Functional Rehabilitation Evaluation of Sensori-Neurologic Outcomes for Multidisciplinary Functional Assessment of Infants and Children Less Than 3 Years of Age

Objective: To determine if a multidisciplinary functional assessment tool can be used in documenting functional recovery in infants and children with neurologic injury. Design: Retrospective analysis. Setting: Tertiary pediatric hospital with inpatient rehabilitation unit. Participants: 30 children ages 0 to 3 years admitted for acute rehabilitation. Interventions: Not applicable. Main Outcome Measure: The Functional Rehabilitation Evaluation of Sensori-Neurologic Outcomes (FRESNO). Results: The majority of patients were victims of nonaccidental trauma (N=11 [37%]) and traumatic brain injury (N=10 [30%]), with the remaining population being treated for various neurologic deficits acquired via other means.

Duodenal injuries in children: beware of child abuse

Purpose It is frequently overlooked that child abuse may result in significant intraabdominal injury, particularly to the duodenum. The authors hypothesized that a significant number of duodenal injuries in young children would be the result of nonaccidental trauma. Methods An 8-year (1995 through 2002) retrospective review of a pediatric level I trauma center database was performed after Institutional Review Board approval was obtained, and information regarding patients with duodenal injury was abstracted. Demographic variables, injury severity, length of stay, mortality rate, and mechanism of injury were examined. Statistical analysis was performed using descriptive statistics and Student’s t test. Statistical significance was defined as P less than .05. Results Over the 8-year study period, 8,968 patients were admitted, 2,179 (24%) were less than 3 years of age. Thirty children (0.3%) suffered injury to the duodenum, with 20 hematomas and 10 perforations. Patients were overwhelmingly boys (80%), with an average age of 7.6 ± 4.4 years and Injury Severity Score (ISS) of 14 ± 10. No patients died. Children were injured by a variety of mechanisms, including collisions involving motor vehicles (n = 9), bicycles (n = 4), and ATVs (n = 2). However, all children less than 4 years of age (n = 8) were victims of nonaccidental trauma, 2.8% of all child abuse admissions. Three of these children suffered perforations of the duodenum. Among the entire population, those children who suffered perforations had a significantly higher ISS (23.7 ± 7.2 v 9.6 ± 7.3; P < .0003) and longer length of stay (27.1 ± 15.3 v 12.6 ± 11.7; P < .007) than those with hematomas Conclusions Injury to the duodenum is unusual in the pediatric trauma patient but does result in significant injury severity and prolonged hospitalization. In the young child, one must maintain a high index of suspicion regarding the etiology of the injury, because a large percentage is potentially the result of child abuse.

Child abuse and neglect: effect on Bayley Scale scores.

Compared to controls, children who were diagnosed as victims of Nonaccidental Trauma or Failure to Thrive had depressed Bayley Scale Mental Index scores, p less than .002 and p less than .0001, respectively. Failure-to-Thrive children also had depressed Bayley Scale Motor Index scores, p less than .0001. Nonaccidental-Trauma children had Mental and Motor Scale range scores, as determined by differences between basal and ceiling items on the Mental and Motor scales, that were a function of measured Mental and Motor Index Scores. Specifically, Nonaccidental-Trauma children with lower Mental Index scores had higher Mental Scale range scores than Nonaccidental-Trauma children with higher Mental Index scores, p less than .003. Control children had Mental Scale range scores that did not differ between the high-low Mental Index score conditions. On the Motor Scale, range scores of Nonaccidental-Trauma children in the high-low Motor Index score conditions did not differ. However, children with higher Motor Index scores had higher Motor Scale range scores than control children with lower Motor Index scores, p less than .02. In addition, the Infant Behavior Record of the Bayley Scales revealed behavior ratings of Nonaccidental-Trauma and Failure-to-Thrive children that differed from Mental and Motor Scale scores on several dimensions. These differences may reflect differential effects of the Nonaccidental-Trauma and Failure-to-Thrive conditions.