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Child Protection Evidence Systematic Review on Fractures

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Child Protection Evidence Systematic Review on Fractures Child Protection Evidence Systematic review on Fractures Published: September 2020 The Royal College of Paediatrics and Child Health (RCPCH) is a registered charity in England and Wales (1057744) and in Scotland (SC038299) Original reviews and content © Cardiff University, funded by NSPCC Updates and new material by RCPCH September 2020 While the format of each review has been revised to fit the style of the College and amalgamated into a comprehensive document, the content remains unchanged until reviewed and new evidence is identified and added to the evidence-base. Updated content will be indicated on individual review 1 pages. Child Protection Evidence – Systematic review on Fractures RCPCH Table of contents Summary ................................................................................................................................................. 4 Evidence summary ................................................................................................................................ 4 Background ............................................................................................................................................. 5 Methodology .......................................................................................................................................... 5 Findings of clinical question 1 .............................................................................................................. 6 Which fractures are indicative of abuse? ........................................................................................... 6 1.1 Rib fractures .............................................................................................................................7 1.2 Costochondral junction fractures ........................................................................................ 8 1.3 Femoral fractures .................................................................................................................... 8 1.4 Humeral fractures .................................................................................................................. 10 1.5 Skull fractures .......................................................................................................................... 11 1.6 Metaphyseal fractures ........................................................................................................... 11 1.7 Pelvic fractures ....................................................................................................................... 14 1.8 Fractures of the hands and feet .......................................................................................... 14 1.9 Mandibular fractures ............................................................................................................. 15 1.10 Sternal fractures ..................................................................................................................... 15 1.11 Clavicular fractures ................................................................................................................ 15 1.12 Vertebral fractures ................................................................................................................. 16 1.13 Key evidence statements ..................................................................................................... 16 1.14 Limitations of review findings ............................................................................................. 16 Findings of clinical question 2 ............................................................................................................ 17 What is the evidence for radiological dating of fractures in children? ........................................ 17 2.1 Key evidence statements .................................................................................................... 22 2.2 Research implications .......................................................................................................... 22 2.3 Limitations of review findings ............................................................................................ 22 Findings of clinical question 3 ............................................................................................................ 23 What radiological investigations should be performed to identify fractures in suspected child abuse? 23 3.1 Skeletal surveys ..................................................................................................................... 23 2 Child Protection Evidence – Systematic review on Fractures RCPCH 3.2 Skeletal survey (SS) versus radionuclide imaging (RNI) ................................................. 27 3.3 Identifying less common abusive fractures ..................................................................... 27 3.4 Key evidence statements ..................................................................................................... 31 3.5 Research implications ........................................................................................................... 31 3.6 Limitations of review findings ............................................................................................. 31 Findings of clinical question 4 ............................................................................................................ 32 Does cardiopulmonary resuscitation cause rib fractures in children? ........................................ 32 4.1 Cardiopulmonary resuscitation-related fractures ........................................................... 32 4.2 Research implications .......................................................................................................... 34 4.3 Limitations of review findings ............................................................................................ 34 Other useful resources ........................................................................................................................ 34 Clinical question 1: Which fractures are indicative of abuse? ....................................................... 34 Clinical question 2: What is the evidence for radiological dating of fractures in children? ..... 38 Clinical question 3: What radiological investigations should be performed to identify fractures in suspected child abuse? .................................................................................................................. 39 Clinical question 4: Does cardiopulmonary resuscitation cause rib fractures in children? ..... 40 References ............................................................................................................................................ 42 Appendix 1 – Methodology ................................................................................................................. 60 Inclusion criteria ................................................................................................................................... 60 Additional inclusion criteria specific review questions .................................................................. 61 Ranking of abuse ................................................................................................................................. 62 Search strategy .................................................................................................................................... 64 Pre-review screening and critical appraisal .................................................................................... 68 Meta-analysis ....................................................................................................................................... 68 Appendix 2 - Related publications .................................................................................................... 70 Publications arising from fractures review ...................................................................................... 70 Primary studies arising from fractures review ................................................................................ 70 Appendix 3 – Flow of studies .............................................................................................................. 71 3 Child Protection Evidence – Systematic review on Fractures RCPCH Summary Fractures have been recorded in as many as 55% of young children who have been physically abused,1-3 18% of whom have multiple fractures.1 Fractures in physical child abuse denote severe assault and young children are at greatest risk of abusive fractures. Many abusive injuries can be clinically occult and investigative strategies are designed to maximise their early detection, potentially preventing escalation of physical abuse to more serious injury. This systematic review has been updated and now evaluates the scientific literature published up until March 2020 that compares abusive and non-abusive fractures in children. There are increasing numbers of high quality studies being published in this field, which continue to address the value of skeletal surveys in different populations and fracture patterns associated with abuse. In the 2020 systematic review update, seven new studies have been included,4-10 most adding to a growing body of literature about classic metaphyseal lesions (CMLs). This includes two studies reviewing the distinguishing features of abusive CMLs,7,9 a study assessing subperiosteal new bone formation with distal tibial CMLs,8
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