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Original Contribution
October 2, 2002

Racial Differences in the Evaluation of Pediatric Fractures for Physical Abuse

Author Affiliations

Author Affiliations: Division of General Pediatrics, Children's Hospital of Philadelphia (Drs Lane, Rubin, and Christian) and University of Pennsylvania School of Medicine (Drs Lane, Rubin, Monteith, and Christian), Philadelphia. Dr Lane is now with the Departments of Pediatrics and Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore. Dr Monteith is now with Childrens National Medical Center, Washington, DC.

JAMA. 2002;288(13):1603-1609. doi:10.1001/jama.288.13.1603

Context Child maltreatment is a significant problem within US society, and minority children have higher rates of substantiated maltreatment than do white children. However, it is unclear whether minority children are abused more frequently than whites or whether their cases are more likely to be reported.

Objectives To determine whether there are racial differences in the evaluation and Child Protective Services (CPS) reporting of young children hospitalized for fractures.

Design, Setting, and Patients Retrospective chart review conducted at an urban US academic children's hospital among 388 children younger than 3 years hospitalized for treatment of an acute primary skull or long-bone fracture between 1994 and 2000. Children with perpetrator-admitted child abuse, metabolic bone disease, birth trauma, or injury caused by vehicular crash were excluded.

Main Outcome Measures Ordering of skeletal surveys and filing reports of suspected abuse.

Results Reports of suspected abuse were filed for 22.5% of white and 52.9% of minority children (P<.001). Abusive injuries, as determined by expert review, were more common among minority children than among white children (27.6% vs 12.5%; P<.001). Minority children aged at least 12 months to 3 years (toddlers) were significantly more likely to have a skeletal survey performed compared with their white counterparts, even after controlling for insurance status, independent expert determination of likelihood of abuse, and appropriateness of performing a skeletal survey (adjusted odds ratio [OR], 8.75; 95% confidence interval [CI], 3.48-22.03; P<.001). This group of children was also more likely to be reported to CPS compared with white toddlers, even after controlling for insurance status and likelihood of abuse (adjusted OR, 4.32; 95% CI, 1.63-11.43; P = .003). By likelihood of abuse, differential ordering of skeletal surveys and reporting of suspected abuse were most pronounced for children at least 12 months old with accidental injuries; however, differences were also noted among toddlers with indeterminate injuries but not among infants or toddlers with abusive injuries. Minority children at least 12 months old with accidental injuries were more than 3 times more likely than their white counterparts to be reported for suspected abuse (for children with Medicaid or no insurance, relative risk [RR], 3.08; 95% CI, 1.37-4.80; for children with private insurance, RR, 3.74; 95% CI, 1.46-6.01).

Conclusion While minority children had higher rates of abusive fractures in our sample, they were also more likely to be evaluated and reported for suspected abuse, even after controlling for the likelihood of abusive injury. This suggests that racial differences do exist in the evaluation and reporting of pediatric fractures for child abuse, particularly in toddlers with accidental injuries.