Open Access Open Badges Research article

Prevalence of abuse among young children with femur fractures: a systematic review

Joanne N Wood123*, Oludolapo Fakeye1, Valerie Mondestin1, David M Rubin123, Russell Localio4 and Chris Feudtner123

Author Affiliations

1 Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, 3535 Market Street, Floor 15, Philadelphia PA19104, Pennsylvania

2 Leonard Davis Institute of Health Economics, Colonial Penn Center, 3641 Locust Walk, Philadelphia 19104, Pennsylvania

3 Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia 19104, Pennsylvania

4 Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia 19104, Pennsylvania

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BMC Pediatrics 2014, 14:169  doi:10.1186/1471-2431-14-169

Published: 2 July 2014



Clinical factors that affect the likelihood of abuse in children with femur fractures have not been well elucidated. Consequently, specifying which children with femur fractures warrant an abuse evaluation is difficult. Therefore the purpose of this study is to estimate the proportion of femur fractures in young children attributable to abuse and to identify demographic, injury and presentation characteristics that affect the probability that femur fractures are secondary to abuse.


We conducted a systematic review of published articles written in English between January 1990 and July 2013 on femur fracture etiology in children less than or equal to 5 years old based on searches in PubMed/MEDLINE and CINAHL databases. Data extraction was based on pre-defined data elements and included study quality indicators. A meta-analysis was not performed due to study population heterogeneity.


Across the 24 studies reviewed, there were a total of 10,717 children less than or equal to 60 months old with femur fractures. Among children less than 12 months old with all types of femur fractures, investigators found abuse rates ranging from 16.7% to 35.2%. Among children 12 months old or greater with femur fractures, abuse rates were lower: from 1.5% - 6.0%. In multiple studies, age less than 12 months, non-ambulatory status, a suspicious history, and the presence of additional injuries were associated with findings of abuse. Diaphyseal fractures were associated with a lower abuse incidence in multiple studies. Fracture side and spiral fracture type, however, were not associated with abuse.


Studies commonly find a high proportion of abuse among children less than 12 months old with femur fractures. The reported trauma history, physical examination findings and radiologic results must be examined for characteristics that increase or decrease the likelihood of abuse determination.

Child abuse; Child maltreatment; Femur fracture; Accident; Trauma