Multicentre study of physical abuse and limb fractures in young children in the East Anglia Region, UK.

OBJECTIVE: To determine if the detection of physical abuse in young children with fractures is of uniform high standard in the East Anglia Region of the UK, and whether we can identify areas for improvement in our detection of high-risk groups. DESIGN: Multicentre retrospective 4-year study. SETTING: 7 hospitals across the East Anglia Region of Britain (East Anglia Paediatric Physical Abuse and Fractures study). PARTICIPANTS: Age groups and fractures indicated as being at higher risk for physical abuse (all children under 12 months of age, and fractures of humerus and femur in children under 36 months of age). OUTCOME MEASURES: Our criterion for physical abuse was the decision of a multiagency child protection case conference (CPCC). RESULTS: Probability of CPCC decision of physical abuse was highest in infants, ranging from 50% of fractures sustained in the first month of life (excluding obstetric injuries) to 10% at 12 months of age. Only 46%-86% of infants (under 12 months) with a fracture were assessed by a paediatrician for physical abuse after their fracture. Significant variation in the use of skeletal surveys and in CPCC decision of physical abuse was noted in children attending different hospitals. CONCLUSIONS: It is a concern that significant variation between hospitals was found in the investigation and detection of physical abuse as confirmed by CPCC decisions. To minimise failure to detect true cases of physical abuse, we recommend that all high-risk children should be assessed by a paediatrician prior to discharge from the emergency department. Our proposed criteria for assessment (where we found probability of CPCC decision of physical abuse was at least 10%) are any child under the age of 12 months with any fracture, under 18 months of age with femur fracture and under 24 months with humeral shaft fracture (not supracondylar).

Serial casting in the treatment of idiopathic toe-walkers and review of the literature.

Idiopathic toe-walking is defined as persistent toe-walking in a normal child in the absence of developmental, neurological or neuromuscular conditions. True idiopathic toe-walking is a rare referral, representing approximately 1:100 new patients seen in the Paediatric Orthopaedic Clinic. A prospective study of idiopathic toe-walking (ITW) was organised between 1999 and 2003. Patients underwent full history, neurological examination and assessment of ankle dorsiflexion, followed by below-knee weight-bearing casting. Forty four developmentally normal children with no delay in walking age were in this study. There was an age range on presentation from 2 years to 14 years 4 months, with median 60.5 months. Sixty eight percent were male. Thirty four percent had a family history of the condition. Following casting, 66% of patients had improved gait on patient and clinician determined outcomes, with the majority of children ceasing to toe-walk. Ankle dorsiflexion significantly improved in those children who were successfully treated (p = 0.001).