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Non-Accidental Trauma: Contemporary Trends In Injury Patterns, Management, and Outcome

Saturday, October 20, 2012: 1:44 PM
Napoleon Ballroom (Hilton Riverside)
Ioanna G. Mazotas, Nicholas A. Hamilton, MD and Martin S. Keller, MD, Pediatric Surgery, Washington University School of Medicine, Saint Louis, MO

Purpose: Non-accidental trauma (NAT) remains a significant cause of morbidity and mortality in the pediatric population. We sought to better define the injury patterns, management, and outcome for these patients.

Methods: Following IRB approval (#201102491), all children managed for NAT at a state-designated level I pediatric trauma center from 1/2003-12/2010 were reviewed. Demographics, injuries, mechanism, perpetrator, management, and outcome were recorded. Data were compared between each half of the study period using Student's t-test and Chi-square (p<0.05 significant).

Results: Over the 8-year period, 325 children (3.0% of trauma registry) carried a diagnosis of injuries related to NAT. Patient demographics included a mean age of 22.52.1 months (range 10 days – 17 years), M:F ratio of 1.6:1, 51.1% Caucasian, 45.5% African American, and mean injury severity score of 12.10.7. Injury mechanisms were blunt force (44.3%), rotational forces (shaking, 20.6%), burn (11.7%), and unknown (23.4%). All children were evaluated with injury-specific imaging modalities along with skeletal survey (84.0%) and head CT (74.2%) as indicated. Screening skeletal surveys identified additional fractures that were not suspected clinically in 23.8% of children. Of the 273 children with skeletal surveys, 147 (53.8%) had follow-up surveys identifying an additional 20 occult fractures. Initial laboratory evaluation consisted of complete blood count (75.7%), comprehensive metabolic panel (72.0%), and coagulation panel (56.6%). The most frequent injuries are shown in the table. Only thermal injuries were more common in children greater than 2 years of age (p<0.05). The majority of patients (81.8%) required no operative intervention. The most common operations performed were burn excision and grafting (19, 38.7% of children with burns), intracranial pressure monitor placement (18, 17.0% of children with TBI), and subdural hematoma evacuation (12, 12.0% of subdural hematomas required evacuation). Overall length of stay was 5.50.4 days (range 1-55), and 33.5% of patients required intensive care unit management. Patients were discharged to home (33.2%), foster care (55.4%), or died in-hospital (10.8%). Over the study period, the total number of children managed for NAT, males, and those under 2 years increased (p<0.05). No changes were noted in injury severity, imaging, laboratory evaluation, length of stay, or mortality.

Conclusion: Non-accidental trauma remains a significant cause of injury in children. The incidence appears to be increasing, particularly among males and younger children. Multiple and occult injuries are common mandating a high index of suspicion and a multidisciplinary approach. These data also support the continued liberal use of screening modalities for the evaluation of these patients.

Table 1: Injuries sustained from NAT


Number of Patients

Percent of Patients

Subdural hematoma



Skull fracture



Retinal hemorrhage



Upper extremity fracture



Lower extremity fracture



Rib fracture



Intra-abdominal injury



Multiple injuries