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Child Abuse & Neglect 73 (2017) 1–7

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Child Abuse & Neglect


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Full length article

Understanding humerus fractures in young children: Abuse or not MARK


abuse?

Norell Rosadoa, , Elizabeth Ryznab, Emalee G. Flahertyc,d
a
John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, United States
b
Harvard Medical School, Boston, MA, United States
c
Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago IL, United States
d
Northwestern University Feinberg School of Medicine, Chicago, IL, United States

AR TI CLE I NF O AB S T R A CT

Keywords: Fractures are the second most common abusive injury occurring in young children, particularly
Fractures those under 2 years of age. The humerus is often affected. To better identify factors dis-
Humerus injuries criminating between abusive and non-abusive humerus fractures, this retrospective study ex-
Child abuse amined the characteristics and mechanisms of injuries causing humerus fractures in children less
than 18 months of age. Electronic medical records were reviewed for eligible patients evaluated
between September 1, 2007 and January 1, 2012 at two children’s hospitals in Chicago, IL. The
main outcome measures were the type of fracture and the etiology of the fracture (abuse vs not
abuse). The 97 eligible patients had 100 humerus fractures. The most common fracture location
was the distal humerus (65%) and the most common fracture type was supracondylar (48%).
Child Protection Teams evaluated 44 patients (45%) and determined that 24 of those had 25
fractures caused by abuse (25% of the total study population).Among children with fractures
determined to have been caused by abuse, the most common location was the distal humerus
(50%) and the most common types were transverse and oblique (25% each); however, transverse
and oblique fractures were also seen in patients whose injuries were determined to have been
non-abusive. A younger age, non-ambulatory developmental stage, and the presence of addi-
tional injuries were significantly associated with abusive fractures. Caregivers did not provide a
mechanism of injury for half of children with abusive fractures, whereas caregivers provided
some explanation for all children with non-abusive fractures.

1. Introduction

Skeletal fractures account for 10–25% of childhood injuries (Sibert, Maddocks, & Brown, 1981; Landin, 1997). Fractures have the
lowest incidence in infancy; the incidence increases as the child ages(Rennie et al., 2007) and becomes ambulatory. The majority of
fractures in children involve the upper extremity(Rennie et al., 2007) and are a consequence of falls, motor vehicle crashes, or other
non-abusive trauma. Occasionally, however, fractures can be caused by child physical abuse.
Fractures are the second most common injury caused by child abuse (Loder & Feinberg, 2007). Even though there is some evi-
dence that the incidence of abusive fractures may be decreasing (Leventhal et al., 2007), skeletal fractures are diagnosed in up to a
quarter of children who have been victims of physical abuse (Belfer, Klein, & Orr, 2001; Day et al., 2006). Fractures of the extremity,

Abbreviations: CML, classic metaphyseal lesion; CPT, child protection team



Corresponding author at: Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States.
E-mail address: nrosado@luriechildrens.org (N. Rosado).

http://dx.doi.org/10.1016/j.chiabu.2017.09.013
Received 17 April 2017; Received in revised form 5 September 2017; Accepted 10 September 2017
0145-2134/ © 2017 Elsevier Ltd. All rights reserved.
N. Rosado et al. Child Abuse & Neglect 73 (2017) 1–7

specifically the humerus and femur, are the second most common location of fractures caused by abuse; most of these inflicted
fractures occur in children less than 2 years of age (Loder & Feinberg, 2007) A systematic review of 32 studies (6 of which specifically
looked at abusive humerus fractures) found that the probability of suspected abuse in a humerus fracture in a child under 3 years of
age was between 0.48 (0.06–0.94) and 0.54 (0.20–0.88) (Kemp et al., 2008a).
The diagnosis of abuse related fractures is missed in 20–30% of young children at their initial medical visits (Ravichandiran et al.,
2010; Thorpe et al., 2014). The diagnosis can be missed for a variety of reasons including incorrect interpretation of the radiographs,
incomplete imaging, acceptance of implausible explanations, and because caregivers were not asked for detailed descriptions of the
injury or about social concerns that place a child at increased risk for abuse. The diagnosis of abuse may be missed particularly in
infants and toddlers because clinicians usually must rely on the caregiver’s history and a caregiver may intentionally provide a false
or misleading explanation for an injury that has been inflicted. O’Neill found that, in 95 of 100 cases of injuries caused by child abuse,
the history was inaccurate or evasive (O'Neill et al., 1973). Failing to identify that a fracture resulted from an abusive injury can place
a child at much higher risk of further abuse and even death (Fluke, Yuan, & Edwards, 1999; Levy et al., 1995).
Not only are infants and toddlers more vulnerable to fractures caused by abuse but children who have been abused are more likely
to have multiple injuries when medically evaluated. Worlock compared the patterns of fractures caused by abuse and non-inflicted
fractures in children less than age 12 years. He found that 80% of the fractures in abused children occurred in children less than 18
months old; none occurred in children over the age of 5 years. In his study, abused children had more than one fracture, ribs were
common fractures, and other associated injuries were more commonly seen (Worlock, Stower, & Barbor, 1986).
All health care professionals, as mandated reporters, should be able to recognize the characteristics of fractures that are suspicious
for abuse and initiate a report to state social services to prevent further injury that could be fatal (Fluke et al., 1999; Levy et al.,
1995). We conducted a retrospective study to systematically examine the description of the mechanism causing a humerus fracture,
the presenting symptoms, the age and developmental capability of the child, and the type and site of the humerus fracture, to
determine if commonalities existed among specific type of injuries causing specific fractures at different stages of development in
infants and toddlers. The goal of this retrospective analysis was to find commonalities that would help clinicians better discriminate
between fractures caused by child physical abuse and unintentional fractures.

2. Methods

The clinical records for all children less than 18 months of age with a humerus fracture treated at Children’s Memorial Hospital
(now Ann & Robert H. Lurie Children’s Hospital of Chicago, IL) and John H. Stroger, Jr. Hospital of Chicago (IL) during a 52 month
period between September 1, 2007 and January 1, 2012 were reviewed retrospectively. Patients were identified through a medical
record search using the International Classification of Diseases 9th revision diagnostic codes for humerus fractures (812, 818, 819,
and 829). Only those patients with a definite fracture of the humerus were included in this study. Because all radiographs were read
by board certified pediatric radiologists at both institutions, the official interpretation was used and radiographs were not further
reviewed. The Institutional Review Boards from both hospitals approved the study.
Children with medical conditions that could predispose to bone fractures (gestational age < 28 weeks, osteogenesis imperfecta,
rickets, osteopenia, or steroid therapy) or those whose fractures could be attributed to birth trauma or motor vehicle collision were
excluded. Because a classic metaphyseal lesion (CML) is a well-described fracture that is highly specific for child abuse (Kleinman,
Marks, & Blackbourne, 1986; Kleinman, Kleinman, & Savageau, 2004), children with a CML as their only humerus fracture were also
excluded from this analysis. If the CML was not the only humerus fracture, it was recorded as an additional fracture.
Demographic information obtained from the record included age (in months) at the time of the injury, gender, race/ethnicity
(white, black, Hispanic, and other), and type of insurance (public or private) as a proxy for socioeconomic status. Whenever available,
the developmental history of the patient was recorded. Information on specific fracture location (proximal, mid-shaft, and distal) and
type of fracture (buckle, transverse, spiral/oblique, supracondylar/condylar, and other) was recorded. Spiral and oblique fractures
were grouped together because it may be difficult to differentiate between the two and consequently some radiologists group them
together when writing their interpretation of the findings. Condylar fractures also were grouped together with supracondylar frac-
tures, because the mechanisms causing the two fractures are similar.
The reason for seeking medical attention along with any history of injury and description of the mechanism of the injury was
extracted from the record. Indirect witness of trauma (i.e., patient left on an elevated surface, cried and was found on the floor after
an unwitnessed incident) were recorded as having a history of injury. If caregivers provided conflicting histories and/or the history
changed in a significant manner (mechanism of incident changed), it was recorded as “changing history.” If no history was given by
the caregiver(s) to explain the injury, it was recorded as “no history of trauma.” When no information was available in the record
about the possible cause for the injury, it was recorded as “unknown.” The different mechanisms recorded in the chart were divided
into the following groups: fall from child’s standing height, fall from sofa or bed (reported heights were between 1.5 and 3 feet), fall
from a distance higher than a sofa or bed, and fall down stairs. Other groups included: “fall not specified” (no description of the fall
recorded), “crush injury” (e.g., father fell on patient’s arm after tripping while holding her) and “hyperflexion/extension injury” (e.g.,
mom grabbed arm to prevent patient from slipping off couch).
Every child had a medical evaluation, including a full history and physical examination by the primary service. Child Protection
Team (CPT) protocols at both hospitals state that consultation by the CPT should be initiated for all children less than 12 months of

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Fig. 1. Total sample and patients evaluated by multidisciplinary child protection team (CPT).

age with a fracture or for children 12 months or older whenever the primary team suspected that the fracture could be as a result of
an abusive injury. Both participating hospitals have well-established CPTs that include board-certified child abuse pediatricians and
dedicated child abuse social workers. To formulate their final opinion, the CPTs utilized information from their medical evaluation,
psychosocial assessment, and from the state social services and law enforcement investigations, when a decision was made to involve
them. Neither state social services nor law enforcement are members of either of the hospital’s CPTs. If state social services and law
enforcement were not involved, the final opinion was made by the hospital’s CPT. The final determination (abuse, not abuse, or
indeterminate) was recorded for those children evaluated by the CPT. For this subgroup of children, analysis of the age, race/
ethnicity, type of insurance, development, mechanism of injury, and location and type of fracture was done comparing the “abuse”
and “not abuse” groups. If the CPT was not consulted, the case was recorded as “not consulted”.

2.1. Statistical analysis

Data was analyzed using SPSS 18.0. A two-sided Pearson’s chi square was used for statistical comparison of gender, race, and
insurance status. The Mann-Whitney U test was used to compare differences in median age, because the age distribution did not
follow a normal distribution. A p-value less than 0.05 was considered significant.

3. Results

3.1. Total sample

Of the 143 children with humerus fractures, 46 children were excluded (36 had fractures caused by birth trauma, 4 had CMLs, 4
had osteopenia, 1 had osteogenesis imperfecta, and 1 was injured in a motor vehicle collision), leaving 97 who met study criteria as
shown in Fig. 1. The median age at presentation was 12 months (range 1–18) (Table 1). The sample was evenly divided between
males and females. Seventy-four percent of children had public insurance, which reflects the patient population at both institutions.
The 97 study subjects had 100 humerus fractures; two children had two fractures of the same bone while a third child had
fractures of both humeri. Of the 97 patients, the distal humerus was the most common site of fracture (65%), followed by the
midshaft (20%) and the proximal humerus (16%). Supracondylar/condylar fractures were the most common type of fracture (48%),
followed by spiral/oblique fractures (23%) and transverse fractures (12%) (Table 3).

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Table 1
Demographics and Development Level.

Total Sample (n = 97) Children with CPT Consults (n = 44)

Abuse (n = 24) Not abuse (n = 15) p-value

Median age (months, range) 12 [1,18] 5 [1, 15] 11 [3, 15] 0.002
Cruising or Walking 14 out of 36a 2 (out of 18)b 7 (out of 10)c 0.001
Females, n (%) 49 (51%) 11 (46%) 8 (53%) 0.648
Race 0.143
Hispanic, n (%) 39 (40%) 7 (29%) 7 (47%) 0.492
White, n (%) 22 (23%) 2 (8%) 4 (27%) ref
Black, n (%) 26 (27%) 14 (58%) 4 (27%) 0.046
Other, n (%) 10 (10%) 1 (4%) 0 0.212
Public insurance, n (%) 74 (76%) 21 (88%) 12 (80%) 0.528

a
61 patients had no notation of developmental capabilities.
b
4 patients did not have development listed; they were not included here.
c
6 patients did not have development listed; they were not included here.

As shown in Table 2, caregivers provided a mechanism of injury for 80% (78/97) of children; the most common explanation was a
fall (63/97 children, or 65%) and in particular a fall from a sofa or bed (32/97, or 33%). Caregivers provided no explanation for 15%
of children (15/97) and changed the history for 3% (3/97); no information about the injury was recorded in the chart of one (1%)
child.
Approximately 80% (78/97) of the children had some notation about symptom(s) in the record. Crying was the most common
symptom described and was documented in 47% of children (46/97) followed by not using the affected limb in 43% cases (42/97).
Caregivers reported hearing an audible sound of the injury in 5% of cases (5/97).

3.2. Analysis of mechanism by fracture type

Supracondylar/condylar fractures. Forty-seven children had supracondylar or condylar fractures of the humerus. The most
common mechanism described for these type of fractures was a fall. The CPT were consulted to evaluate 10/47 cases. Of the 5 cases
determined to have been caused by child physical abuse only 1 had an isolated supracondylar fracture (comminuted). In the other 4
cases more than one fracture was present: one patient had 2 fractures, two patients had 6 fractures, and one patient had 9 fractures.
The mean age for supracondylar fractures was 13.8 months (median 15, range 3–18).
Spiral/oblique fractures. Twenty-two children had spiral/oblique fractures. The CPT were consulted to evaluate 19 of those cases.
Eleven (50%) spiral/oblique fractures were determined to be caused by child abuse and in two cases the cause was indeterminate.
The most common mechanism described in those cases determined not to be abuse, was a fall from a sofa or bed. The mean age for
spiral/oblique fractures was 6.9 months (median 5.5, range 1–17). Children with fractures determined to have been caused by abuse
were slightly younger than those with fractures determined not to have been caused by abuse (5.3 months vs. 8.3 months).
Transverse fractures. All 12 children who suffered transverse fractures received CPT consults. Of these children, 6 (50%) had
injuries determined to have been caused by child physical abuse and 5 (41%) had fractures determined not to have been caused by
abuse. The cause of 1 child’s injury was indeterminate. The mean age of those children with a transverse fracture was 6.3 months
(median 5, range 2–13).
Of the 6 children with injuries determined to have been caused by abuse, caregivers provided no history of an injury for 2

Table 2
Comparison of histories provided by caretakers.

Total Sample (n = 97) Children Receiving a CPT Consult n = 44

Abuse (n = 24a) Not abuse (n = 15a)

History of trauma provided 78 (80%) 8 (33%) 15 (100%)


Fall 63 (65%) 4 (17%) 10 (67%)
-from standing height 11 0 1
-from sofa or bed 32 4 6
-from higher than sofa or bed 11 0 3
-down stairs 2 0 0
-unknown height 7 0 0
Crush injury 2 (2%) 0 2 (13%)
Twisting/Pullin /Torsion 0 4 (17%) 3 (20%)
No history of trauma provided 15 (15%) 12 (50%) 0
Changing history 3 (3%) 3 (13%) 0
Not knowna 1 (1%) 1 (4%) 0

a
Does not include 5 children with injuries of indeterminate cause.

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Table 3
Injury comparison between the abuse and not abuse groups.

Children Receiving a CPT Consult (n = 44)

Total Sample (n = 97) Abuse (n = 24) Not Abuse (n = 15)

Type of Injury, n (%)


- Buckle 5 (5%) 1 (4%) 0
- Condylar/Supracondylar 47 (48%) 5 (21%) 4 (27%)
- Spiral/Oblique 22 (23%) 11 (46%) 6 (40%)
- Transverse 12 (12%) 6 (25%) 5 (33%)
- Not Specified 8 (8%) 0 0
- Othera 5 (5%) 3 (13%) 0

Site of Injury, n (%)


- Distal 63 (65%) 12 (50%) 7 (47%)
- Middle 19 (20%) 9 (38%) 7 (47%)
- Proximal 16 (16%) 5 (21%) 1 (7%)
- Not Specified 1 (1%) 0 0

Associated Injuries, n (%)


- Bruise over fracture 2 (2%) 1 (4%) 0
- Other bruises 6 (6%) 4 (17%) 0
- Other fractures 3 (3%) 2 (8%) 0
- Subdural hematoma 7 (7%) 7 (29%) 0
- Otherb 4 (4%) 2 (8%) 1 (7%)

a
Other includes: comminuted, metaphyseal, and physeal fractures.
b
Other includes: superficial skin abrasions, soft tissue swelling, and a pustule.

children; 1 of these 2 children had a total of 14 fractures. Caregivers changed their explanation of 1 child’s injury; that child also had
bruises suspicious for abuse. Caregivers of another child said the injury was caused by a fall from sofa or bed, but the proximal site of
the fracture was deemed inconsistent with the explanation for that fracture. Caregivers described a hyperextension/flexion me-
chanism as the cause of 2 children’s transverse fractures. One caregiver described moving the child's wrist while he was reaching back
in his stationary swing and the other caregiver disclosed snapping child's left arm back while holding down her back. The latter child
had a contralateral distal buckle fracture with callus formation seen on skeletal survey.
Of the 5 children with injuries determined to have been not abusive, the caregivers provided an unchanging history of the event
causing the transverse fracture. Two of the 5 children fell from a height higher than a sofa or bed, 1 of whom had a fracture of the
proximal humerus and the other had fractures of the mid-humerus and the radius. Two children fell from the height of a sofa or bed, 1
child fell from a hammock; the hammock movement may have increased the forces generating the fracture. The other child could not
break the fall when falling backwards from a bed because he/she had an Erb’s palsy in the other extremity. Another child suffered a
hyperextension of the humerus when her sister grabbed her arm as she was falling.
Buckle fractures. Five children suffered buckle fractures, all proximal. Of these 5 children, 3 had a history of falling from a bed
and 1 fell from a height higher than sofa or bed. All of the buckle fractures were symptomatic; 3 children were not using the limb.
Only one child was referred to CPT and that child was determined to have a buckle fracture caused by abuse. The caregivers could
provide no explanation for a 6 month old infant’s humerus fracture. The infant had 2 fractures, a proximal buckle fracture and a distal
condylar fracture. After the injuries were reported and investigated by state social services, the family said that the child had caught
the arm in the slats of the bed.

3.3. Children with a CPT consult

Forty five percent of the children (44/97) received a CPT consult. Even though consultation by the CPT should have been initiated
for all children < 12 months with a fracture per protocol at both hospitals, the CPT was not consulted in 9/44 (20%) children <
12 months with a fracture. Of the 97 eligible patients, the final determination was recorded as “abuse” in 25% (24/97), “not abuse”
in 15% (15/97), and “indeterminate” in 5% (5/97) (Fig. 1). Black children were more likely to receive a CPT consult [OR = 2.1 (95%
CI 1.1–4.1)], but were not more likely to have an abuse determination (p = 0.06).The majority of children [63% (61/97)] did not
have developmental history noted in the chart. Of the children that had their development charted, 14/36 (39%) were ambulatory
(cruising or walking).
Children with injuries determined to have been caused by abuse were significantly younger than those with injuries determined
not to have been caused by abuse with a median age of 5 months (range 1–15) vs. 11 months (range 3–15), respectively (p = 0.002).
In addition, 16/18 (89%) children in the “abuse” group were not yet cruising or crawling, compared to 3/10 (30%) children in the
“not abuse” group (p = 0.001). There were no other significant demographic differences between the two groups (“abuse” vs. “not
abuse”)
Falls were the most common mechanism described causing the fractures determined as “not abuse” (10/15, 67%) compared to
17% (4/24) of the children determined to have fractures caused by “abuse.” Half of the children in the “abuse” group (12/24) had no
explanation provided for the injury, while some history was provided for all 15 children in the “not abuse” group. Children in the “not

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abuse” group did not have additional injuries. Ten children in the “abuse” group had additional injuries, including bruises, in-
tracranial injuries, superficial skin lesions, and other fractures; two patients had CMLs of the humerus (Table 3).

4. Discussion

This study adds additional information to the current literature about the characteristics, mechanisms, and presentation of
abusive and non-abusive humerus fractures in young children. Our study analyzed 97 subjects less than 18 months of age. The
proportion of children with humerus fractures attributable to abuse was 25% among the entire study population (45% of the total
sample received a comprehensive child abuse evaluation) and 55% among the children systematically evaluated for child abuse by
CPTs. This is comparable to other studies which had smaller sample sizes (Kemp et al., 2008a). In his study of young children with
humerus fractures, Strait found that 9 of 25 children (36%) less than 15 months of age were diagnosed to have fractures caused by
child abuse (Strait, Siegel, & Shapiro, 1995). Pandya’s study included 43 children less than 18 months of age; 13 (30%) were de-
termined to have fractures caused by abuse (Pandya et al., 2010).
Falls were the most common explanation provided for humerus fractures, particularly falls from beds. It is not uncommon for
young children to suffer falls and even falls from heights. In one survey of parents, 40% of children sustained at least 1 fall from a
height before age 2 years (Haney et al., 2010). In that same survey, bruises were the most common resulting injury and none of the
children suffered a fracture. Another study of children who suffered orthopedic injuries from falls off a bed or sofa found that radius
and ulna fractures were the most common fracture experienced followed by supracondylar fractures and lateral condyle fractures of
the humerus, which are the same types of humerus fractures most commonly found in our study (Hennrikus, Shaw, & Gerardi, 2003).
Although most of the children in our study who had fractures caused by falls fell from at least the height of a sofa or bed, about
10% fell from a standing height. Hansoti found that fractures are more likely to be associated with falls from heights of 50 cm or
greater, but he could not determine what height was likely cause a fracture and concluded that other factors such as rotational forces
and the impacting surface likely played a role in causing a fracture (Hansoti & Beattie, 2005).
Supracondylar fractures were the most common type of fracture and the distal humerus was the most common site of fractures in
this age group. About 15% of all fractures are elbow fractures and the distal humerus is the site of 85% of all elbow fractures in
children (Shrader, 2008). Supracondylar fractures account for 50–70% of all elbow fractures in children. They are usually caused by a
fall on an out-stretched hand. Only 1 of the 17 supracondylar fractures in our sample was determined to have been caused by child
physical abuse. This is not surprising because a systematic review of other studies found that supracondylar fractures particularly in
ambulatory children are unlikely to be caused by abuse (Kemp et al., 2008b).
Spiral/oblique and transverse fractures were not infrequently seen, accounting for 23% and 12% of humerus fractures in the
entire study sample. Given prior studies indicating their association with abuse (Kemp et al., 2008a; Kowal-Vern et al., 1992;
Leventhal et al., 1993; Strait et al., 1995), unsurprisingly most children with spiral/oblique fractures and all children with transverse
fractures were referred for CPT evaluation. After a thorough investigation, about half were determined to have been abusive. The
other half were found to have been non-abusive and occurred in instances of falls with increased force.
Crying was the most common symptom at presentation. About half of the children were not using their arm. Caregivers reported
hearing an audible sound or crack in a small number of children. They also noted an obvious deformity of the limb in only a small
number of children.
Children with fractures caused by abuse were younger than the children with non-inflicted fractures. Other studies have also
shown that young age is a risk for child abuse (Strait et al., 1995).
Caregivers provided no explanation for an injury or a changing explanation for the injury in the majority of children with
fractures identified as caused by abuse. Although the absent or changing history may have been a factor in determining that the injury
was caused by abuse, most of these children had other injuries or factors leading to the diagnosis of abuse.
Because each child received a complete history and thorough CPT evaluation at the time of presentation, our study was more
rigorous in evaluating humerus fractures and determining abuse or not abuse when compared to some studies which determined the
cause of injury retrospectively (Shaw et al., 1997).
Limitations: Because this is a retrospective study, some information was inconsistently recorded in the medical chart, particularly
regarding developmental level and presence of symptoms, thus limiting the analysis. Additionally, this study did not retrospectively
review all 97 cases in order to systematically identify the likelihood of abuse. Cases of abuse may have been missed for the patients
who were never referred for CPT evaluation by providers at the time of presentation (55% of patients did not receive CPT evalua-
tions). Finally, this study attempted to confirm whether certain factors (like an absent or changing history) were suggestive of abuse;
however, these factors likely influenced which children were referred for CPT evaluation in the first place, which could result in
circular thinking. This limitation is difficult to escape in retrospective studies of child abuse; however, most of the children had
several factors supporting a diagnosis of child abuse and the children were evaluated by multidisciplinary CPTs and had imaging
reviewed by pediatric radiologists who were not members of the CPT, adding reliability to the assessment.

5. Conclusion

Humerus fractures in children less than 18 months of age are most commonly caused by a fall, particularly a fall from a bed or
sofa. The distal humerus is the most common site of fracture and supracondyle/condylar fractures are the most common type of
humerus fractures. When evaluating humerus fractures in young children, clinicians must perform a thorough medical evaluation
including a detailed history for the mechanism of the injury. Certain indicators can be used to guide clinician’s judgement when

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determining if a humerus fractures is caused by abuse, such as a lack of or inconsistent history, young age (particularly those who are
not yet cruising), and presence of additional injuries. The presence of other overt or occult injuries should be assessed with laboratory
studies and medical imaging if indicated.

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