Missed Fractures in Infants Presenting to the Emergency Department with Fussiness

Objectives The aim of this study was to evaluate incidence of prior fussy emergency visits in infants with subsequently diagnosed fractures suggestive of abuse. Methods This was a retrospective chart review of infants younger than 6 months who presented to the pediatric emergency department (ED) between January 1, 2006, and December 31, 2011. Inclusion criteria included age 0 to 6 months, discharge diagnosis including “fracture,” “broken” (or break), or “trauma” or any child abuse diagnosis or chief complaint of “fussy” or “crying” as documented in the electronic medical record by the triage nurse. Results Three thousand seven hundred thirty-two charts were reviewed, and 279 infants with fractures were identified. Eighteen (6.5%) of 279 infants had a prior ED visit for fussiness without an obvious source. Of these, 2 had a witnessed event causing their fracture, and therefore the fracture was not considered concerning for abuse. The remaining 16 had fractures concerning for abuse. Mean age was 2.5 (SD, 1.2) months. Fifteen (83%) of 18 infants were 3 months or younger at the time of the fussy visit. The mean interval between the first and second ED visits was 27 days (median, 20 days). Thirty-nine percent were evaluated by a pediatric emergency medicine–trained physician during their initial fussy visit, whereas 78% were evaluated by pediatric emergency medicine–trained physician during their subsequent visit. Most common injuries were multiple types of fractures followed by extremity and rib fractures. Conclusions Fractures concerning for child abuse are an important cause of unexplained fussiness in infants presenting to the pediatric ED. A high index of suspicion is essential for prompt diagnosis and likely prevention of other abuse.