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Background

Abusive abdominal trauma may be difficult to diagnose, and even serious abdominal injury may be missed. Screening for occult abdominal trauma (OAT) has been recommended by child abuse experts. However, it is unclear how often screening occurs, and what factors are associated with screening.

Objectives

(1) To determine the prevalence of OAT in a sample of children with suspected physical abuse. (2) To assess the frequency of OAT screening. (3) To assess factors associated with screening.

Patients and Methods

Charts of children evaluated for abusive injury were identified via a search of hospital discharge codes. Identified charts were reviewed to determine whether OAT screening occurred. Data were collected regarding results of screening tests, abusive injuries identified, family demographics, and characteristics of the emergency department visit.

Results

Screening occurred in 51 of 244 eligible children (20%). Positive screens were identified in 41% of those screened, and 9% of the total sample. 5% of children aged 12–23 months had OAT identified by imaging studies. Screening occurred more often in children presenting with probable abusive head trauma [OR=20.4, 95% CI (3.6–114.6), p<0..01] compared to those presenting with other injuries. Subspecialty consultation from the Child Protection Team [OR=8.5, 95% CI (3.5–20.7), p<0.01] and other subspecialists [OR=24.3, 95% CI (7.1–83.3), p<0.01] also increased the likelihood that OAT screening would occur.

Conclusions

Our findings support OAT screening with liver and pancreatic enzymes for physically abused children. This study also supports the importance of subspecialty input, especially that of a Child Protection Team. Although many identified injuries may not require treatment, their role in confirming, or demonstrating increased severity of maltreatment can play a critical role in protecting children.

Background

To identify facilitators of, and barriers to, screening for child abuse in emergency departments (ED) through interviews with ED staff, members of the hospital Board, and related experts.

Methods

This qualitative study is based on semi-structured interviews with 27 professionals from seven Dutch hospitals (i.e. seven pediatricians, two surgeons, six ED nurses, six ED managers and six hospital Board members). The resulting list of facilitators/barriers was subsequently discussed with five experts in child abuse and one implementation expert. The results are ordered using the Child Abuse Framework of the Dutch Health Care Inspectorate that legally requires screening for child abuse.

Results

Lack of knowledge of child abuse, communication with parents in the case of suspected abuse, and lack of time for development of policy and cases are barriers for ED staff to screen for child abuse. For Board members, lack of means and time, and a high turnover of ED staff are impediments to improving their child abuse policy. Screening can be promoted by training ED staff to better recognize child abuse, improving communication skills, appointing an attendant specifically for child abuse, explicit support of the screening policy by management, and by national implementation of an approved protocol and validated screening instrument.

Conclusions

ED staff are motivated to work according to the Dutch Health Care Inspectorate requirements but experiences many barriers, particularly communication with parents of children suspected of being abused. Introduction of a national child abuse protocol can improve screening on child abuse at EDs.

Aims: To evaluate how often children seen in paediatric accident & emergency (A&E) departments were suspected of abuse or neglect, and to explore some of the correlates of suspected child maltreatment.

Methods: Multicentre, cross-sectional study of 15 randomised census days during a six month period. Trained research assistants working with local paediatric staff completed a purpose made anonymised checklist covering sociodemographic and medical information. A six point suspicion index was used to rate compatibility with child maltreatment based on the occurrence of observable harm. Statistical analysis was carried out on the basis that a score of 4 or more was suspicious of child maltreatment. Nineteen hospitals provided standardised paediatric A&E consultation data on 0–14 year olds presenting between 10 am and 10 pm.

Results: Of 10 175 assessed children, 204 aroused suspicion of child maltreatment (95% CI 163 to 214 per 10 000). In a logistic regression model of suspected maltreatment statistically significant associations were found with socioeconomic disadvantage, children living in single parent families, and developmental delay. There was no correlation with pre-school age, male gender, foreign origin, or living in urban areas.

Conclusions: Child maltreatment based on immediate scoring of suspicion, focused on observable harm, occurred in 2% of a representative sample of paediatric emergency consultations in Italy. This was more common if there were associated social and developmental vulnerabilities. True prevalence of child maltreatment in emergency departments remains elusive because of changing definitions and forensic validation problems.

Objective: To assess the compliance with national guidelines on child protection procedures and provision of paediatric services in major English emergency departments.

Background: Victims of child abuse may present to emergency departments, and successful detection and management depends on adequate child protection procedures being in place. Two official documents published in 1999 provide recommendations for child protection procedures and staffing arrangements in emergency departments, and these can be used as standards for audit.

Methods: Structured telephone questionnaire survey of English emergency departments receiving at least 18 000 child attenders per year.

Results: Many of the standards are being met. Areas for improvement include: better access to child protection registers with clearer indications for their use; improved communication with other professionals such as the school nurse; more formal training for medical and nursing staff in the identification of potential indicators of child abuse; and improved awareness of local named professionals with expertise in child protection. More consultants with training in paediatric emergency medicine and more registered children's nurses are needed.

Conclusion: Many nationally agreed recommendations are being met, but there is a need for improved training, increased numbers of specialised staff, and improved communication between professionals. There is considerable variation in practice between departments.

Objectives: To investigate whether cases of possible non-accidental injury as identified using five risk indicators give rise to any subjective concerns of child abuse.

Methods: Questionnaires were completed by the triage nurse and attending doctor for every child attending the general hospitals of the North Western Health Board, with an injury, during a six month period. The questionnaires included an assessment of subjective concerns about the injury occurrence and five risk indicators of child abuse.

Results: Children presenting with an injury who had two or more positive indicators failed to raise subjective concerns in the attending emergency department staff.

Conclusions: The introduction of a policy of identifying positive indicators from the five risk indicators of child abuse needs additional computer support within emergency departments.

The emergency room (ER) represents the main system entry for crises-based health care visits. It is estimated that 2% to 10% of children visiting the ER are victims of child abuse and neglect (CAN). Therefore, ER personnel may be the first hospital contact and opportunity for CAN victims to be recognised. Early diagnosis of CAN is important, as without early identification and intervention, about one in three children will suffer subsequent abuse. This educational paper provides the reader with an up-to-date and in-depth overview of the current screening methods for CAN at the ER. Conclusion: We believe that a combined approach, using a checklist with risk factors for CAN, a structured clinical assessment and inspection of the undressed patient (called ‘top–toe’ inspection) and a system of standard referral of all children from parents who attend the ER because of alcohol or drugs intoxication, severe psychiatric disorders or with injuries due to intimate partner violence, is the most promising procedure for the early diagnosis of CAN in the ER setting.

Objective

To examine whether pre-abuse rates and patterns of emergency department (ED) visits between children with supported child abuse and age-matched controls are useful markers for abuse risk.

Study design

A population-based case-control study using probabilistic linkage of four statewide data sets. Cases were abused children <13 years, identified between 1/1/01–12/31/02. For each case, a birth date matched population-based control was obtained. Outcome measures were rate ratios of ED visits in cases compared with controls.

Results

9795 cases and 9795 controls met inclusion criteria. 4574 cases (47%) had an ED visit; thus linked to the ED database versus 2647 controls (27%). The crude ED visit rate per 10 000 person-days of exposure was 8.2 visits for cases compared with 3.9 visits for controls. Cases were almost twice as likely as controls (adjusted rate ratio = 1.8, 95% CI:1.5, 1.8) to have had a prior ED visit. Leading ED discharge diagnoses were similar for both groups.

Conclusions

Children with supported child abuse have higher ED use prior to abuse diagnosis, when compared with the general pediatric population. However, neither the rate of ED use nor the pattern of diagnoses offers sufficient specificity to be useful markers of risk for abuse.

Background

Child abuse and neglect is an important international health problem with unacceptable levels of morbidity and mortality. Although maltreatment as a cause of injury is estimated to be only 1% or less of the injured children attending the emergency room, the consequences of both missed child abuse cases and wrong suspicions are substantial. Therefore, the accuracy of ongoing detection at emergency rooms by health care professionals is highly important. Internationally, several diagnostic instruments or strategies for child abuse detection are used at emergency rooms, but their diagnostic value is still unknown. The aim of the study 'Child Abuse Inventory at Emergency Rooms' (CHAIN-ER) is to assess if active structured inquiry by emergency room staff can accurately detect physical maltreatment in children presenting at emergency rooms with physical injury.

Methods/design

CHAIN-ER is a multi-centre, cross-sectional study with 6 months diagnostic follow-up. Five thousand children aged 0-7 presenting with injury at an emergency room will be included. The index test - the SPUTOVAMO-R questionnaire- is to be tested for its diagnostic value against the decision of an expert panel. All SPUTOVAMO-R positives and a 15% random sample of the SPUTOVAMO-R negatives will undergo the same systematic diagnostic work up, which consists of an adequate history being taken by a pediatrician, inquiry with other health care providers by structured questionnaires in order to obtain child abuse predictors, and by additional follow-up information. Eventually, an expert panel (reference test) determines the true presence or absence of child abuse.

Discussion

CHAIN-ER will determine both positive and negative predictive value of a child abuse detection instrument used in the emergency room. We mention a benefit of the use of an expert panel and of the use of complete data. Conducting a diagnostic accuracy study on a child abuse detection instrument is also accompanied by scientific hurdles, such as the lack of an accepted reference standard and potential (non-) response. Notwithstanding these scientific challenges, CHAIN-ER will provide accurate data on the predictive value of SPUTOVAMO-R.

Aims: To improve the care of children who are victims of child sexual abuse (CSA) by routinely assessing eligibility for HIV post-exposure prophylaxis (PEP) and to investigate the feasibility, safety, and efficacy of such treatment started in a paediatric emergency department in Malawi.

Methods: Children presenting to the Queen Elizabeth Central Hospital, Blantyre between 1 January 2004 and 31 December 2004 with a history of alleged CSA were assessed for eligibility for HIV PEP and followed prospectively for six months.

Results: A total of 64 children presented with a history of alleged CSA in the 12 month period; 17 were offered PEP. The remainder were not offered PEP because of absence of physical signs of abuse (n = 20), delay in presentation beyond 72 hours from assault (n = 11), repeated sexual abuse in the preceding six months (n = 15), and HIV infection found on initial testing (n = 1). No family refused an HIV test. No side effects due to antiretroviral therapy were reported. Of the 17 children commenced on PEP, 11 returned for review after one month, seven returned at three months, and two of 15 returned at six months post-assault. None have seroconverted.

Conclusions: In a resource-poor setting with a high HIV prevalence, HIV PEP following CSA is acceptable, safe, and feasible. HIV PEP should be incorporated in to national guidelines in countries with a high community prevalence of HIV infection.

In a prospective study the number of children attending the Royal Liverpool Children's Hospital (RLCH) for examination after allegations of child abuse, and the type of abuse involved, was recorded from July to December 1990. The cost to the hospital of these examinations and initial investigations was assessed. The study was carried out in the major and minor accident and emergency departments and the Rainbow Centre of the RLCH. In six months 181 children were examined. Cases of sexual abuse and non-accidental injury were seen in equal numbers. Girls outnumbered boys and 60% were referred by social services. The costs over the six month period were 31,739 pounds. The minimum projected annual cost is 63,500 pounds. We conclude that the cost of running an effective service for the initial assessment of children who are possible victims of child abuse is considerable in practical terms and in medical time.

Background

Child abuse presents in many different forms: physical, sexual, psychological, and neglect. The orthopaedic surgeon is involved mostly with physical abuse but should be aware of the other forms. There is limited training regarding child abuse, and the documentation is poor when a patient is at risk for abuse. There is a considerable risk to children when abuse is not recognized.

Questions/purposes

In this review, we (1) define abuse, (2) describe the incidence and demographic characteristics of abuse, (3) describe the orthopaedic manifestations of abuse, and (4) define the orthopaedic surgeon’s role in cases of abuse.

Methods

We performed a PubMed literature review and a search of the Department of Health and Human Services Web site. The Pediatric Orthopaedic Surgery of North America trauma symposium was referenced and expanded to create this review.

Results

Recognition and awareness of child abuse are the primary tasks of the orthopaedic surgeon. Skin trauma is more common than fractures, yet fractures are the most common radiographic finding. Patients with fractures who are younger than 3 years, particularly those younger than 1 year, should be evaluated for abuse. No fracture type or location is pathognomonic. Management in the majority of fracture cases resulting from abuse is nonoperative casting or splinting.

Conclusions

The role of the orthopaedic surgeon in suspected cases of child abuse includes (1) obtaining a good history and making a thorough physical examination; (2) obtaining the appropriate radiographs and notifying the appropriate services; and (3) participating in and communicating with a multidisciplinary team to manage the patients.

Background

Emergency departments (EDs) may be the first point at which children who have been subject to abuse or neglect come into contact with professionals who are able to act for their protection. In order to ascertain current procedures for identifying and managing child abuse, we conducted a survey of EDs in England and Northern Ireland.

Methods

Questionnaires were sent to the lead professionals in a random sample of 81 EDs in England and 20 in Northern Ireland. Departments were asked to provide copies of their procedures for child protection. These were analysed qualitatively using a structured template.

Results

A total of 74 questionnaires were returned. 91.3% of departments had written protocols for child protection. Of these, 27 provided copies of their protocols for analysis. Factors judged to improve the practical usefulness of protocols included: those that were brief; were specific to the department; incorporated both medical and nursing management; included relevant contact details; included a single page flow chart which could be accessed separately. 25/71 (35.2%) departments reported that they used a checklist to highlight concerns. The most common factors on the checklists included an inconsistent history or one which did not match the examination; frequent attendances; delay in presentation; or concerns about the child's appearance or behaviour, or the parent–child interaction.

Conclusions

There is a lack of consistency in the approach to identifying and responding to child abuse in EDs. Drawing on the results of this survey, we are able to suggest good practice guidelines for the management of suspected child abuse in EDs. Minimum standards could improve management and facilitate clinical audit and relevant training.

OBJECTIVE: To audit the appropriateness of skill radiography in children attending an accident and emergency (A&E) department with head injuries. METHODS: 569 children presenting to a large teaching hospital A&E unit were retrospectively audited. The indications for radiography according to British published guidelines and American published guidelines were compared with the actual requests for radiography. The criteria for admission from the two guidelines were also compared with the actual admissions. RESULTS: 50% of children presenting with head injury actually had skull radiography. If British guidelines for the use of skull radiography had been complied with, 63% of children should have had radiography, but if American guidelines had been used, 18% would have required radiography. All the actual fractures identified were in this 18%. CONCLUSIONS: The British guidelines overinvestigate children with head injury. This seems to have been recognised clinically, and the doctors did not adhere to the guidelines. Neither did they adhere to the American guidelines, which would have resulted in a further reduction in radiography. All the fractures identified were covered by the American guidelines. The American guidelines for skull radiography can be safely used in a British A&E unit.

A 15-month-old African–American boy receiving chemotherapy for Wilms tumour was diagnosed to have a fracture of left femur at the emergency department (ED) of our hospital. A month earlier, the patient had been seen at the same ED for a fracture of right femur. The skeletal survey this time also showed an old posterior rib fracture. Child abuse was suspected. The child’s custody was transferred to the maternal grandparents. However, 2 months later while with the grandparents, he sustained a fracture of the left distal tibia. This led to an investigation for osteogenesis imperfecta (OI). The child was found to have a collagen mutation, COL1A1, strongly suggesting that the child’s multiple fractures were most likely due to OI.

The child had no physical stigmata of classical OI except for blue sclera. Multiple bone fractures alone without other physical signs of abuse should always raise a possibility of OI.

Trial registration number:

POG9440

Objective:

To assess rates of substance abuse (including tobacco, alcohol, and drug abuse) as well as rates of intimate partner violence (IPV) among African-American women seen in an urban emergency department (ED).

Methods:

Eligible participants included all African-American women between the ages of 21–55 years old who were seen in an urban ED for any complaint and triaged to the waiting room. Eligible women who consented to participate completed a computer-based survey that focused on demographic information and general health questions, as well as standardized instruments to screen for alcohol abuse, tobacco abuse, and illicit drug use. This analysis uses results from a larger study evaluating the effects of providing patients with targeted educational literature based on the results of their screening.

Results:

Six-hundred ten women were surveyed; 430 women reported being in a relationship in the past year and among these, 85 women (20%) screened positive for IPV. Women who screened positive for IPV were significantly more likely to also screen positive for tobacco abuse (56% vs. 37.5%, p< 0.001), alcohol abuse (47.1% vs. 23.2%, p < 0.001), and drug abuse (44.7% vs. 9.5%, p<0.001). Women who screened positive for IPV were also more likely to screen positive for depression and report social isolation.

Conclusions:

African-American women seen in the ED, who screen positive for IPV, are at significantly higher risk of drug, alcohol, tobacco abuse, depression and social isolation than women who do not screen positive for IPV. These findings have important implications for ED-based and community-based social services for women who are victims of intimate partner violence.

A search of accident and emergency department records showed that 61% of 85 children registered as being physically or sexually abused by the Department of Community Paediatrics at St James's University Hospital, Leeds, England, were found to have visited the accident and emergency department an average of 2.9 times before the diagnosis was made. Fifty-two per cent of the attendances were because of problems other than injuries. Staff of accident and emergency departments should be aware that abused children present with medical diagnoses as well as trauma. Increased awareness may result in earlier diagnosis of abuse in some of these children.

Introduction:

There is ongoing controversy regarding the appropriate use of narcotic analgesia for patients presenting frequently to the emergency department (ED) with subjective acute exacerbations of pain. “Are we treating pain or enabling addiction?”

Objectives:

To determine whether the presence of specific factors could be used to identify adults complaining of acute exacerbations of pain for suspected drug addiction, to estimate the percentage of drag addicted patients, to assess the physicians’ ability to detect drug addiction and to evaluate Interrater reliability.

Methods:

A Drug Abuse Screening Test (DAST-20) was administered to 76 ED patients who presented with acute exacerbations of pain and either multiple ED visits for similar pain complaints, specific narcotic requests, or “allergies” to non-narcotics. The DAST-20 was also administered to 74 age-matched controls. Treating ED physicians rated their suspicion for drug addiction using a visual analog scale (VAS).

Results:

The overall estimation of drug addiction based on the DAST-20 survey was 17.3% (26/150). Twenty-one percent (16/76) of the analgesia subjects and 13.5% (10/74) of the control subjects scored positive for drug addiction as measured by the DAST-20. Of the analgesia subjects with positive DAST-20 scores for drug addiction, 43.8% (7/16) had multiple ED visits, 43.8% (7/16) requested specific narcotics and 6.3% (1/16) reported “allergies” to non-narcotics. There was no correlation between the VAS scores and the DAST-20 scores. There was a significant correlation between resident and attending VAS scores for their suspicion for drug addiction.

Conclusion:

There exists a clinically significant drug addiction problem among ED patients presenting with acute exacerbations of pain and among low-acuity patients who do not present to the ED for pain management.

At Children's Hospital of Michigan there seemed to be a disproportionate number of white infants with shaken baby syndrome (SBS) relative to the proportion of white infants in our physically abused population. All reports of suspected child abuse on children less than or equal to 18 months from Children's Hospital from 1980-1985 were reviewed. The total number of abused children 18 months or younger was 545 (447 black, 87 white, 1 unknown). There were 20 children in the SBS group. Eight of 87 (9%) of white abused infants had SBS compared with 12 of 447 (2.7%) of black abused infants. The occurrence of SBS in white abused infants was disproportionately higher than in blacks. This finding has not been previously reported. Before generalizations can be made, additional data must be obtained.

Problem

Child abuse is easily overlooked in a busy emergency department.

Design

Two stage audit of 1000 children before and after introduction of reminder flowchart.

Background and setting

An emergency department in a suburban teaching hospital seeing about 4000 injured preschool children a year.

Key measures for improvement

Number of records in which intentional injury was adequately documented and considered and the number of children referred for further assessment before and after introduction of reminder flowchart into emergency department notes.

Strategies for change

Nurses were asked to insert a reminder flowchart for assessing intentional injury into the notes of all children aged 0-5 years attending the department with any injury and to record the results of checking the child protection register.

Effect of change

Documentation of all eight indicators that intentional injury had been considered had increased in the second audit. Records of compatibility of history with injury and consistency of history increased from less than 2% to more than 70% (P<0.0001). More children were referred for further assessment in the second audit than the first, although the difference was not significant (6 (0.6%) v 14 (1.4%), P=0.072). The general level of awareness and vigilance increased in the second audit, even for children whose records did not contain the flowchart.

Lessons learnt

Inclusion of a simple reminder flowchart in the notes of injured preschool children attending the emergency department increases awareness, consideration, and documentation of intentional injury. Rates of referral for further assessment also increase.

Background

Association between psychiatric morbidity and substance abuse among adolescent has been reported. However prevalence and pattern of such dysfunctions are unknown in our environment.

Aims

To determine the prevalence of psychosocial dysfunction and depressive symptoms among adolescents who abuse substance and also note the influence of socio-demographic factors and type of substance on the pattern of dysfuction.

Method

A cross-sectional study was carried out among 900 adolescents selected from 29 secondary schools in Enugu metropolis. A multi-stage sampling procedure was used to select the students. The student drug use questionnaire was used to screen respondents for substance abuse. Those who were abusing substance and matched controls (non substance abusers) were assessed for psychiatric symptoms using the 35-item Paediatric Symptom Checklist (PSC) and the Zung Self-rating Depression Scale (SDS). Social classification was done using the parental educational attainment and occupation.

Result

A total of 290 students were current substance abusers. The substances most commonly abused were alcohol (31.6%), cola nitida (kola nut) (20.7%) and coffee (15.7%). Using the PSC scale, 70 (24.1%) subjects compared to 29 (10.7%) of the controls had scores in the morbidity range of ≥ 28 for psychosocial dysfuction. This was statistically significant (χ2 = 17.57 p = 0.001). Fifty-four subjects (18.6%) had scores in the morbidity range of ≥ 50 for depressive symptoms using the Zung SDS compared to 21 (7.7%) of controls. This was statistically significant (χ2 = 14.43, p = 0.001). Prevalence of dysfunction was not significantly related to age in both subjects and controls (χ2 = 4.62, p = 0.010, χ2 = 4.8, p = 0.10 respectively). Also using both scales, there was no significant relationship between psychosocial dysfunction and gender or social class in both subjects and control. The prevalence of dysfuction using both scales was significantly higher in multiple abusers compared to single abusers. Subjects abusing alcohol scored more on both scales compared to those abusing other substances.

Conclusion

Prevalence of psychosocial dysfunction is higher in adolescents abusing substance compare to controls. The prevalence of psychiatric morbidity was not related to the age, gender or social classes in the study population.We advocate periodic screening of our adolescents for drug abuse regular evaluation of such group for possible psychopathology.

A total of 1117 visits by patients to two hospital emergency departments and 15 family physicians' offices for nontraumatic complaints over two 2-week periods were studied. Patients visiting the two settings fell into two distinct subgroups, and they appeared to select where to seek care by the acuteness and duration of the complaint. Several highly significant differences were noted between the two groups: those who visited an emergency department had complaints of shorter duration, underwent more investigations (which more often gave abnormal results), were more likely to undergo investigation for mental symptoms, had more consultations, received counselling and drug therapy less often (but intramuscular injections more often), were admitted to hospital more often, returned for further care for the same complaint less often, complied with disposal instructions less often, were more likely to receive fewer than 5 days' care and were less likely to receive more than 31 days' care; those without a family physician more often received additional care (were referred, admitted or asked to return).

Purpose

To characterize differences in child abuse management resources between urban and rural emergency departments (EDs).

Methods

We surveyed ED directors and nurse managers at hospitals in Oregon to gain information about available abuse-related resources. Chi-square analysis was used to test differences between urban and rural EDs. Multivariate analysis was performed to examine the association between a variety of hospital characteristics, in addition to rural location, and presence of child abuse resources.

Findings

Fifty-five Oregon hospitals were surveyed. A smaller proportion of rural EDs had written abuse policies (62% vs 95%, P = .006) or on-site child abuse advocates (35% vs 71%, P = .009). Thirty-two percent of rural EDs had none of the examined abuse resources (vs 0% of urban EDs, P = .01). Of hospital characteristics studied in the multivariate model, only rural location was associated with decreased availability of child abuse resources (OR 0.19 [95% CI, 0.05 – 0.70]).

Conclusions

Rural EDs have fewer resources than urban EDs for the management of child abuse. Other studied hospital characteristics were not associated with availability of abuse resources. Further work is needed to identify barriers to resource utilization and to create resources that can be made accessible to all ED settings.

Objectives—To assess how frequently and adequately information relating to the possibility of non-accidental injury (NAI) is documented and considered by doctors assessing pre-school children with burns and scalds in the accident and emergency (A&E) department, and to determine the effect of introducing a routine reminder mechanism into the A&E notes, coupled with an improved programme of NAI education and awareness.

Methods—The records of 100 pre-school children attending an A&E department with a burn or scald were reviewed against nine pre-determined standards. Changes in policy were instituted, through a programme of education and the use of a reminder checklist, and the next 100 cases re-audited against the same checklist.

Results—Groups one and two were similar in their demographic characteristics. The reminder checklist was included in 60% of group two notes, and when included was completed in 97%. The child protection register was rarely consulted. There was a statistically significant increase in recording the following: time that the injury had occurred, the consistency of the history, the compatibility of the injury with the history given, the consideration of the possibility of NAI, the general state and behaviour of the child and the presence or absence of any other injuries. The rate of referral for a further opinion regarding the possibility of NAI increased from 0 to 3%, but failed to reach statistical significance.

Conclusions—Prevailing awareness and documentation regarding the possibility of NAI was found to be poor, but a programme of intervention combining education and the use of a reminder checklist improved both awareness and documentation of NAI, as well as referral rates for further assessment. This strategy may prove applicable to children of all ages and injury types, reducing the number of cases of child abuse that are overlooked in the A&E department.

Aim: To compare the effectiveness of radiological skeletal survey and bone scintigraphy for the detection of bony injuries in cases of suspected child abuse.

Methods: All cases with a discharge diagnosis of child abuse that presented to the Royal Children's Hospital between 1989 and 1998 were retrieved, and those children that had undergone both skeletal survey and bone scintigraphy (radioisotope bone scan) within a 48 hour period were included in this study. Both examinations followed rigid departmental protocols and protocols remained identical throughout the timeframe of the study. The reports of the skeletal surveys and bone scans were retrospectively reviewed by a paediatric radiology fellow and consultant paediatric radiologist.

Results: The total number of bony injuries identified was 124 in 30 children. Of these, 64 were identified on bone scan and 77 on skeletal survey. Rib fractures represented 60/124 (48%) of the bony injuries and were present in 16/30 children (53%), of which 62.5% had multiple rib fractures. Excluding rib fractures, there were 64 (52%) bony injuries, of which 33% were seen on both imaging modalities, 44% were seen on skeletal survey only, and 25% were seen on bone scans alone. Metaphyseal lesions typical of child abuse were present in 20 cases (31%) on skeletal survey; only 35% of these were identified on bone scan. Six children (20%) had normal skeletal surveys, with abnormalities shown on bone scan. There were three children (10%) with normal bone scans who were shown to have injuries radiographically.

Conclusions: Skeletal survey and bone scintigraphy are complementary studies in the evaluation of non-accidental injury, and should both be performed in cases of suspected child abuse.

AIMS—To examine the extent of undiagnosed child abuse in Greece by studying young children with femoral fractures, which may be associated with abuse.
METHODS—Fifty seven consecutive cases of children under 6 years of age with femoral fracture were identified from the Emergency Department Injury Surveillance System database. Controls were 4162 children with other orthopaedic injuries from the same database.
RESULTS—Whereas in the literature about one third of femoral injuries among young children are attributed to child abuse, no child in the studied series had been diagnosed or even investigated in this context. Nevertheless, the pattern of occurrence of femoral injuries was compatible with that of child abuse, in that patients were frequently very young boys of low socioeconomic status, and the accident had frequently occurred under poorly identified or implausible conditions at time periods when most family members were crowded at home.
CONCLUSIONS—Epidemiological risk factors for child abuse characterise femoral fractures in young children in Greece. It appears that child abuse is present in this country as in most other cultures. There is a clear need for refocusing medical personnel and hospital social services so that the problem is revealed, quantified, and appropriately dealt with.