OBJECTIVES: Because physicians may have difficulty distinguishing accidental fractures from those that are caused by abuse, abusive fractures may be at risk for delayed recognition; therefore, the primary objective of this study was to determine how frequently abusive fractures were missed by physicians during previous examinations. A secondary objective was to determine clinical predictors that are associated with unrecognized abuse.

METHODS: Children who were younger than 3 years and presented to a large academic children's hospital from January 1993 to December 2007 and received a diagnosis of abusive fractures by a multidisciplinary child protective team were included in this retrospective review. The main outcome measures included the proportion of children who had abusive fractures and had at least 1 previous physician visit with diagnosis of abuse not identified and predictors that were independently associated with missed abuse.

RESULTS: Of 258 patients with abusive fractures, 54 (20.9%) had at least 1 previous physician visit at which abuse was missed. The median time to correct diagnosis from the first visit was 8 days (minimum: 1; maximum: 160). Independent predictors of missed abuse were male gender, extremity versus axially located fracture, and presentation to a primary care setting versus pediatric emergency department or to a general versus pediatric emergency department.

CONCLUSIONS: One fifth of children with abuse-related fractures are missed during the initial medical visit. In particular, boys who present to a primary care or a general emergency department setting with an extremity fracture are at a particularly high risk for delayed diagnosis.

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