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Multicentre study of physical abuse and limb fractures in young children in the East Anglia Region, UK
  1. Piers D Mitchell1,
  2. Richard Brown2,
  3. Tengyao Wang3,
  4. Rajen D Shah3,
  5. Richard J Samworth3,
  6. Sue Deakin4,
  7. Phillip Edge5,
  8. Ivan Hudson6,
  9. Rachel Hutchinson7,
  10. Kuldeep Stohr8,
  11. Mark Latimer1,
  12. Rajan Natarajan9,
  13. Sultan Qasim5,
  14. Andreas Rehm8,
  15. Anish Sanghrajka7,
  16. Elizabeth Tissingh6,
  17. Georgina M Wright4
  1. 1 Department of Orthopaedics, Peterborough City Hospital, Peterborough, UK
  2. 2 Department of Paediatrics, Peterborough City Hospital, Peterborough, UK
  3. 3 Statistical Laboratory, University of Cambridge, Cambridge, UK
  4. 4 Department of Orthopaedics, West Suffolk Hospital, Suffolk, UK
  5. 5 Department of Orthopaedics, Bedford Hospital NHS Trust, Bedford, UK
  6. 6 Department of Orthopaedics, Ipswich Hospital, Ipswich, UK
  7. 7 Department of Orthopaedics, Norfolk and Norwich Hospital, Norwich, UK
  8. 8 Department of Orthopaedics, Addenbrooke’s Hospital, Cambridge, UK
  9. 9 Department of Orthopaedics, Northampton General Hospital, Northampton, UK
  1. Correspondence to Dr Piers D Mitchell, Peterborough City Hospital, Peterborough, UK; piers.mitchell{at}


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).

  • child abuse
  • musculoskeletal
  • inflicted injury
  • child protection
  • fracture

Statistics from


  • Contributors PDM instigated the study, designed the study, obtained HRA approval, recruited the hospitals to join the study, collated the data and wrote the paper. RB contributed to the study design and towards writing the paper. TW, RDS and RJS performed the statistical analysis. All other authors collected data from their hospitals and commented on the paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval NHS Health Research Authority (IRAS project ID 251113, REC reference 19/HRA/0292).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement In order to ensure patient anonymity, the journal editors have requested that we do not include our raw data in this publication, even in an anonymised form.

  • Correction notice This paper has been corrected since it was published Online First. In the second section of the results (Decision of a CPCC that fractures were due to physical abuse), in the sentence ‘The likelihood that a fracture in children aged 0-364 days would lead to a CPCC decision of physical abuse was 0.83/1000 of the total at-risk population’, the fraction should read ‘0.21/1000’. Similarly, in the sentence ‘The likelihood of such a CPCC decision of physical abuse in cases of fracture of the femur or humerus (excluding supracondylar) in children under the age of 3 years was much lower at 0.12/1000 and 0.10/1000 respectively’, the fractions should read ‘0.03/1000 and 0.025/1000 respectively’.

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