Fractures in children under three presenting to A&E Fractures can be sign of NAI so as health professionals we need to be vigilant when assessing these children. NAI cases presenting with fractur are missed. Daniel Pelka presented to A&E aged 3.5yrs with broken arm & bruises. Dr E Payne, Dr H Murch & Dr C Woolley Ysbyty Ystrad Fawr Hospital, Aneurin Bevan University Health Board

Concerning features (RCPCH Child Protection Companion 2008) Age Doesn’t fit the injury Doesn’t fit with development Inconsistent history Unwitnessed Inappropriate parental response Repeated attendance Known to social services New CP Companion out in 2013 but this wasn’t out for the time period we conducted our audit plus chapter on fractures hasn’t changed much at all. The younger the child, the greater the likelihood of abuse. “Infants who are immobile rarely have accidental injuries”

Types of fracture suspicious of abuse (RCPCH Child Protection Companion 2008) Multiple fractures Humeral Rib fractures Femoral fractures (non-mobile child) Spinal fractures Metaphyseal fractures Skull fracture. Humeral #: Spiral fracture of humerus & any humeral fracture other than supracondylar fracture Rib #: Posterior rib fractures. Spinal #: Most commonly occur in cervical or lower thoraco-lumbar area so full spinal views required on x-ray. C-spine # can occur when vigorously shaken. Metaphyseal #: Rare (unless after birth trauma) and only found if looked for carefully. If <2 yrs may indicate abuse, particularly if femoral. Skull #: Especially of concern: occipital, depressed #, growing #, complex #, multiple, wide #, # crossing suture line, assoc with intra-cranial injury. History of fall < 3 feet rarely produces #. Under 1 year: up to 88% abusive skull # occur under 1 year of age.

Audit aims To study fractures seen in children under 3yrs in A&E during 2012-13. To evaluate the documentation & assessment as recommended by RCPCH Child Protection Companion 2008. at this first point of contact

Method Retrospective analysis of medical records for children under 3 years with fracture presenting to A&E in two Gwent hospitals. N = 106 A 13 month retrospective analysis of medical records was carried out for all children aged less than 3 presenting to the ED department in RGH & YYF from January 2012-January 2013. The cases were found through clinical coding and fracture clinic. Jan 2012- Feb 2013 information request for Children aged < 3 yrs presenting to A&E with fracture. N= 70 Children < 3yrs referred to fracture clinic. N=106 Documentation: No mechanism of injury documented in 3.5%. Whether injury witnessed not documented in 20%. Mobility of child not documented in 76%.

Age distribution N=106 F 54, M 52. Local ED practice: Children <1yr with # reviewed by or d/w A&E consultant / paeds. (A&E doctors asked whether NAI considered when entering patient onto Symphony (since 2001 audit). HV informed when child discharged from A&E.) 3 cases 6 mo: 1. 6 mo female, swelling to side of head, # parietal bone. No Hx. Bruise also on thigh with no Hx. CPR checked, d/w senior & referred to paeds & SS (appropriate). 2. 6mo male, parent carrying baby down stairs and fell, distal femoral #, seen by paeds. 3. 6 mo male, clavicle #. Rolled off bed but unwitnessed. Crying when moved his arm. NAI not considered, CPR not checked & no other action taken. Therefore one case <1 yr did not follow local ED practice. N=106 F 54, M 52.

Site of fracture Concerning fractures: 1 Skull # (6mo NAI) 3 Humeral # 1 Femoral # in non-mobile child 12 Metaphyseal # (6 under 2 yrs, 1 was femoral and 1 case was femoral and under 2 yrs, therefore 8/12 concerning.) = 17/106 cases with concerning fractures (16%)

Risk factors for NAI No mechanism of injury 8.5% Delay in presentation 23% Unwitnessed injury 3.5% No mechanism of injury in 9 cases. All had additional risk factors. Action taken in 4. 2 cases dismissed as child interacting well with the parent. Some concerning cases such as 2 yr old with # femur but no mechanism & no action taken. Delay in presentation in 25. (Not included those where no mechanism of action as no obvious event to start clock from.) Two concerning cases were 2.5yr old, metaphyseal fracture of tibia following fall, no action taken & 20 mo old fell off quad bike & buckle # raduis, no action. 4 unwitnessed injuries (not included those with no mechanism of action as can’t witness an event which hasn’t happened): Most discussed with senior. 2.5 yrs old thought to have fallen off slide, supracondylar # 6 mo old crying when moved arm , ?fell off bed, no action 2.5 yr jumped & fell, toe #, d/w/ senior 2.5 yr fell, supracondylar #, d/w/ senior.

Action 6/32 discussed when 1 risk factor 2/9 discussed when 2 risk factors 0/1 discussed when 3 risk factors 1/2 discussed when 4 risk factors Overall 44/106 (41%) cases had at least one RFx (similar to 2001 audit 43/97). 20% (9) of cases with at least one risk factor were discussed with A&E senior or paeds. Overall, only 2 cases were discussed with paediatrics & 1 with social services (6 mo old with swelling to head, no history, parietal # and bruise to thigh & 18 mo with swollen leg & not weight bearing after fall down 4-5 steps, witnessed, displaced transverse # femur). 4 RFx in 2: 6mo # parietal bone >NAI and case 40. Case 40: 21 month female Not using R arm ?Fell down 4 carpeted stairs Not witnessed Buckle # distal radius 11 A&E admissions including facial injury with torn frenum, 2 pulled elbows. No action taken by doctor Nurse referred as CIN Observations: Is delay in presentation or number of previous admissions acknowledged? Delay / prev attendances on triage card Only RGH A&E card asks whether injury witnessed or not. YYF card does not. Doctors reassured too easily by nice interaction between parent & child Unclear from card if other injuries are looked for. Coding issue as missed 36 cases when searched for children with #.

Conclusions Adherence to departmental guidelines in 2/3 cases. Lack of recognition of risk factors for NAI. Very few referrals to paediatrics & social services. Opportunities for discussions about NAI are missed. Not all children under 1 year with fracture were discussed. Lack of recognition of the risk factors for NAI. Lack of documentation of risk factors. Very few referrals to paediatrics. Not following local departmental guidelines or RCPCH guidelines. Inadequate history & documentation. Opportunities for discussions re NAI are missed as risk factors not recognised.

Intervention Mandatory training in Child Protection (e-LFH) for A&E juniors. A&E triggers: A&E database to include red flags for NAI. Paediatric nurse triaging to discuss with A&E senior. RGH & YYF A&E cards Local A&E guideline: all children <1 yr with fracture reviewed by or d/w A&E consultant / paeds.

Thank you