Published online June 1, 2005
PEDIATRICS Vol. 115 No. 6 June 2005, pp. 1712-1722 (doi:10.1542/peds.2004-0614)
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Femur Fractures Resulting From Stair Falls Among Children: An Injury Plausibility Model

Mary Clyde Pierce, MD*,{ddagger}, Gina E. Bertocci, PhD, PE*,{ddagger},§,||, Janine E. Janosky, PhD, Fernando Aguel, BS{ddagger},#, Ernest Deemer, MS{ddagger},#, Morey Moreland, MD**, Danielle K. B. Boal, MD{ddagger}{ddagger},§§, Sylvia Garcia, MD*, Sandra Herr, MD*, Noel Zuckerbraun, MD* and Eva Vogeley, MD*,{ddagger}

* Department of Pediatrics, University of Pittsburgh, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
§ Department of Rehabilitation Science and Technology, University of Pittsburgh, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
|| Department of Bioengineering, University of Pittsburgh, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
Department of Family Medicine and Clinical Epidemiology, University of Pittsburgh, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
# Department of Biomedical Engineering, University of Pittsburgh, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
** Department of Orthopedic Surgery, University of Pittsburgh, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
{ddagger} Injury Risk Assessment and Prevention Laboratory, University of Pittsburgh, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
{ddagger}{ddagger} Department of Radiology, Section of Pediatric Radiology, Milton S. Hershey Medical Center, Pennsylvania State University, University Park, Pennsylvania
§§ Department of Pediatrics, Section of Pediatric Radiology, Milton S. Hershey Medical Center, Pennsylvania State University, University Park, Pennsylvania

Background. Stair falls are common among young children and are also common false histories in cases of child abuse. When a child presents with a femur fracture and a stair-fall history, a judgment of plausibility must be made. A lack of objective injury and biomechanical data makes plausibility determination more difficult. Our objective was to characterize key features associated with femur fractures from reported stair falls, to develop a model for assessing injury plausibility (IP).

Methods. Children 2 to 36 months of age who presented with a femur fracture from a reported stair fall were studied prospectively. Detailed history recording, examinations, fracture characterization, and injury scene analyses were conducted, and biomechanical measures associated with injury prediction were calculated. With our proposed IP model, all cases were then scored for the detail of history, biomechanical compatibility of fracture morphologic features, time to seeking care, and presence of other injuries.

Results. Twenty-nine children were diagnosed with a femur fracture resulting from a reported stair fall. The IP model made a clear distinction between 2 groups, designated plausible and suspicious. Significant differences were observed for the detail of history, biomechanical compatibility of fracture, time to seeking care, presence of other injuries, and total IP scores. In the plausible group, the minimal linear momentum associated with a transverse fracture was almost 10-fold greater than that for spiral or buckle fracture types.

Conclusions. This study adds new information to the current body of knowledge regarding injury biomechanics and fractures among children. The IP model provides an objective means of assessing plausibility of reported stair-fall–related femur fractures and identifies key characteristics to facilitate decision-making.

Key Words: femur fracture • child abuse • stair fall • biomechanics

Abbreviations: CML, classic metaphyseal lesion • IP, injury plausibility • CT, computed tomographic • HQS, history quality scale • CPT, child protection team

Accepted Nov 16, 2004.