Keywords
child abuse - bone fractures - violence - negligence
Introduction
Violence against children has been present in humanity since primitive times and is
often linked to the educational process at home, characterized by any acts, omissions,
or negligence in the care provided to the child and which can result in death, emotional
or physical harm, abuse or sexual exploitation.[1]
[2]
In the United States, of 680 thousand cases of violence against children, 75.0% were
related to neglect, 18.0% to physical violence, and 8.0% to sexual violence[3]
[4]
[5]
[6] - for every 1000 children, 9.1 suffer aggression,[4]
[5] only 8 out of 100 cases of physical violence in the U.S. are reported.[7] There is recidivism in up to 50.0% and, in these, the risk of death reaches 10.0%.[7]
In Brazil, physical aggression in minors varies between 20.0%[8] and 35.1%.[1] In 2019, there were 159,063 complaints of mistreatment by Disque Direitos Humanos
(Disque 100 [Call Human Rights]), an increase of 15.0% compared to 2018.[9] Of these 86,837 (55.0%) referred to domestic violence against children and adolescents:
neglect (38.0%), psychological violence (23.0%), physical violence (21.0%), sexual
violence (11.0%), exploitation of child labor (3.0%) and others (3.0%).[9]
Many of these acts of violence do not leave physical marks. When present, they are
associated with soft tissue injuries (more prevalent), with those affecting the head
and abdomen regions being the main causes of death in this group.[6]
[10] Bone fractures are the second most common finding in victims of violence.[1]
[3]
[6]
[7] Up to about 50.0% of fracture occurrences occur in the first year of life - and
a third of these types of injuries occur in those under 3 years of age.[3]
[6]
[11] They are the result of child violence. Suspicion should be advanced with caution
when the lesions do not correspond to the mechanism of trauma or the declared history.[2]
[3]
[6]
[7]
[12]
[13]
Thermal damage, unexplained soft tissue or skull injuries, rib and/or multiple fractures,
delay in seeking medical attention, or any injury to a child who is not yet walking
should draw the attention of the healthcare professional.[2]
[3]
[4]
[7] Spinal injuries are rare in children, but they can happen in victims of violence.[3]
[14] Children with disabilities require increased attention, as they are a risk group
for violence,[6]
[7]
[10]
[15] are at greater risk of osteopenia than those without disabilities, which may predispose
to pathological fractures,[4] differential diagnoses of maltreatment.[6]
[7]
Orthogonal radiographs of the skull, spine, long bones, hands, and feet are relevant
in cases of suspected violence.[3]
[6]
[7]
[12]
[16]
[17]
[18] However, they do not replace the anamnesis since it is necessary to confirm the
compatibility of the report of the trauma mechanism with that evidenced in the image.[2]
[3]
[6]
[7]
[13]
[14]
Age is one of the most important characteristics in distinguishing between accidental
trauma and violence. An example is tibia fractures, which are highly suspected in
children who are of preambulatory age and may be accidental in young children who
are already walking.[3]
[6]
[7]
[19]
The diagnosis of violence in the health sector[1]
[2]
[6]
[7]
[19] and notification to the responsible bodies avoids worse outcomes, such as emotional
and physical sequelae and even death, especially in cases in which the victim suffers
several aggressions over time in a chronic form.[1]
[6]
[7]
[10]
[11]
[19]
[20]
[21]
[22]
[23] Whereas neglect is the most frequent type of child abuse,[2]
[3]
[7]
[11]
[23]
[24] it is observed that the incidence of injuries in these cases can be reduced through
a preventive approach with parents, guiding them to avoid accident-prone scenarios,
including those typical of each age.[2]
[6]
[7]
[19]
To monitor, identify, and even prevent cases of mistreatment of children and adolescents,
since 2001, Brazil has compulsorily adopted the notification of suspected or confirmed
cases that have been attended to in the establishments of the Unified Health System
([Sistema Único de Saúde] SUS). This notification should be forwarded to municipal
epidemiological surveillance and a protection agency.[25] From these records, health authorities and managers can assemble the profile of
those involved and their impact,[21]
[25] to develop relevant public policies to prevent and manage this sad aggravation.
This study, therefore, aims to describe the profile of children with maltreatment
notification who present fractures and their related factors in a pediatric orthopedic
reference center in Southern Brazil.
Methods
This is a cross-sectional study, with data analysis of children's medical records
(ages 0 to 15 incomplete) notified by mistreatment in the emergency room of a pediatric
hospital in Santa Catarina from January 2016 to June 2020.
The notifications were selected according to the International Classification of Diseases
(ICD-10), with the possibility of outcome in fractures and/or deformities of orthopedic
management[7]
[11]
[26]; availability of information in the medical records; and standardizing terms: “motorcycle
accident,” “collision,” and “car/automobile accident” to “automobile accident.” The
records that contained more than one item selected for the “type of violence” field
were divided into two or more, allowing a more faithful analysis.
Variables related to the victim are categorized into age (age groups), sex (male or
female), race (white and non-white), presence or absence of disability/disorder, and
the municipality of residence (capital or other). Those related to the perpetrator:
number of involved, gender (male or female), suspicion of alcohol use, bond/degree
of kinship with the victim (father, mother, stepfather, stepmother, boyfriend, ex-boyfriend,
brother, friends, caregiver, friend, unknown, person in an institutional relationship
or others, specifying them) were grouped, generating the variable “known” and “unknown.”
Concerning violence, a typology was found (neglect, physical, psychological, suicide
attempt, and others), being categorized into “neglect,” “physical,” and “others” (together
with the others previously listed), and death as a result of aggression. Automobile
accidents with a record in the victim's medical record of the non-use of legally provided
safety devices were considered negligence.
In addition to manually verifying the notification forms, an analysis of the records
in the patients' medical records was performed, aiming to investigate the outcome:
“presence of fractures.” They were categorized in terms of presence (yes or no) based
on the orthopedist's clinical and radiological diagnosis, topography (whether in the
upper limbs, lower limbs, axial skeleton, or two or more body segments), and the need
for surgical intervention.
The data were analyzed using the Statistical Package for the Social Sciences, version 22.0, by descriptive statistics in simple frequency and proportion. Binary
logistic regression was employed, using the chi-square or Fisher's exact tests in
the crude model (variables with p < 0,20). The selection method was used backward for the adjusted analysis, with results expressed in odds ratio (or) and respective
confidence intervals (CI) of 95%. p < 0.05 was considered significant.
In April 2020, a systematized search of the PubMed database (US National Library of Medicine National Institutes of Health) on child maltreatment yielded 182 articles ([Table 1] and [Fig. 1]).
Table 1
|
PubMed
|
Child abuse x child X fractures x notification
|
|
(“child abuse” [Mesh] OR “child abuse” OR “abused children” OR “abused child” OR “childhood
abuse” OR “childhood violence” OR “violence against children” OR “violence toward
children” OR “Nonaccidental Trauma in Children” OR “infant Apparent Life-Threatening
Event” [Mesh] OR
“Infantile Apparent Life-Threatening Event”) AND (“fractures, bone”[MeSH Terms] OR
“fractures” OR “fracture”) AND (“2015/01/01”[PDAT]: “2020/12/31”[PDAT]) AND “last
5 years”[PDat] AND Humans[Mesh] AND (English[lang] OR French[lang] OR Portuguese[lang]
OR Spanish[lang]) AND ((infant[MeSH] OR child[MeSH] OR adolescent[MeSH]) OR infant[MeSH:noexp]
OR child, preschool[MeSH] OR infant, newborn[MeSH] OR infant[MeSH] OR adolescent[MeSH]
OR child[MeSH:noexp])
|
Fig. 1 Search Strategy on Child Maltreatment With Bone Fractures, Pubmed: 2015-2020. Source:
www.prisma.statement.gov [Data from the author].
The study was approved by the Institutional Research Ethics Committee (Consolidated
Opinion 4.203.338/2020).
Results
From January 2016 to December 2020, 276 notifications of suspected or confirmed cases
of interpersonal or self-inflicted violence were made, corresponding to a total of
253 children and adolescents. No records confirming or excluding the diagnosis of
fractures were found in 6 of the 276 cases, leaving 270 notifications for analysis.
Regarding the characteristics of children and adolescents reported as victims of maltreatment
described in [Table 1], there was a predominance of males (54.7%), over 10 years of age (30.1%), of white
ethnicity (89.4%), without disabilities (94.0%) and who inhabited cities that were
not Florianópolis (65.2%). The age of the victim showed a significant difference according
to sex. Most of the victims were boys aged 10-15 years (p < 0.05).
Table 1
|
Variables
|
Total
|
Female
|
Male
|
p-value
|
|
n (%)
|
n (%)
|
CI95%
|
n (%)
|
CI95%
|
|
|
n
|
276 (100)
|
125 (45.3)
|
–
|
151 (54.7)
|
–
|
|
|
Age† (n = 276)
|
|
|
|
|
|
0.031[b]
|
|
0-29 days
|
9 (3.2)
|
6 (4.8)
|
2.1–10.3
|
3 (2.0)
|
0.6–6.1
|
|
|
30d – 1 year
|
73 (26.4)
|
38 (30.4)
|
22.9–39.1
|
35 (23.2)
|
17.1–30.7
|
|
|
2 |–6 years
|
62 (22.5)
|
34 (27.2)
|
20.0–35.8
|
28 (18.5)
|
13.1–25.6
|
|
|
6 |–10 years
|
49 (17.8)
|
19 (15.2)
|
9.8–22.7
|
30 (19.9)
|
14.2–27.1
|
|
|
10 |–15 years
|
83 (30.1)
|
28 (22.4)
|
15.9–30.7
|
55 (36.4)
|
29.1–44.5
|
|
|
Ethnicity* (n = 274)
|
|
|
|
|
|
0.994[a]
|
|
White
|
245 (89.4)
|
110 (89.4)
|
82.5–93.8
|
135 (89.4)
|
83.3–93.4
|
|
Not White
|
29 (10.6)
|
13 (10.5)
|
6.2–17.5
|
16 (10.6)
|
6.6–16.7
|
|
Disability* (n = 275)
|
|
|
|
|
|
0.232[b]
|
|
No
|
187 (94.0)
|
86 (96.6)
|
89.9–98.9
|
101 (91.8)
|
89.9–95.7
|
|
|
Yes
|
12 (6.0)
|
3 (3.4)
|
1.1–10.1
|
9 (8.2)
|
4.2–15.1
|
|
Municipality of residence* (n = 273)
|
|
|
|
|
|
0.189[a]
|
|
Florianópolis
|
95 (34.8)
|
38 (30.7)
|
23.1–39.4
|
57 (38.3)
|
30.7–46.4
|
|
|
Other‡
|
178 (65.2)
|
86 (69.4)
|
60.6–76.9
|
92 (61.7)
|
53.6–69.3
|
|
The sex distribution of the perpetrators of the aggression concerning the sex of the
victim was statistically significant (p < 0,05). In 57.4% of the notifications, the authorship of these violences was linked
to at least two suspects who acted jointly, mostly parents (50.2%), without suspicion
of alcohol use in 91.3% of the notifications. Acquaintances predominated (96.0%) ([Table 2]).
Table 2
|
Variables
|
Total
|
Female
|
Male
|
p-value[a]
|
|
n (%)
|
n (%)
|
CI95%
|
n (%)
|
CI95%
|
|
|
Sex* (n = 248)
|
|
|
|
|
|
0.001
[a]
|
|
Male
|
55 (22.2)
|
18 (15.5)
|
9.9–23.4
|
37 (28.0)
|
21.0–36.4
|
|
|
Female
|
55 (22.2)
|
37 (31.9)
|
24.0–41.0
|
18 (13.6)
|
8.7–20.7
|
|
Perpetrators of both sexes involved in the assault
|
138 (55.7)
|
61 (52.6)
|
43.3–61.6
|
77 (58.3)
|
49.6–66.5
|
|
|
Bond with the victim*(n = 251)
|
|
|
|
|
|
0.865[b]
|
|
Mother
|
39 (15.5)
|
22 (18.5)
|
12.4–26.6
|
17 (12.8)
|
8.1–19.8
|
|
|
Father
|
25 (10.0)
|
12 (10.1)
|
5.7–17.0
|
13 (9.9)
|
5.8–16.3
|
|
|
Both[†]
|
126 (50.2)
|
56 (47.1)
|
38.2–56.2
|
70 (53.0)
|
44.3–61.5
|
|
|
Mother + others‡
|
13 (5.18)
|
7 (5.8)
|
2.8–11.9
|
6 (4.6)
|
2.0–9.8
|
|
|
Father + others‡
|
1 (0.40)
|
0 (0)
|
0 -0
|
1 (0.8)
|
0.1–5.3
|
|
|
Own person
|
14 (5.58)
|
8 (6.7)
|
3.4–13.0
|
6 (4.6)
|
2.0–9.8
|
|
|
Unknown
|
10 (3.98)
|
4 (3.4)
|
1.2–8.7
|
6 (4.6)
|
2.0–9.8
|
|
|
Acquaintance or Relative
|
22 (8.76)
|
10 (8.4)
|
4.5–15.0
|
12 (9.1)
|
5.2–15.4
|
|
|
Father + Mother + Others
|
1 (0.40)
|
0 (0)
|
0 -0
|
1 (0.8)
|
0.1–5.3
|
|
|
Bond with the victim
dichotomized* (
n = 251)
|
|
|
|
|
|
0.752[b]
|
|
Known
|
241 (96.0)
|
115 (96.4)
|
91.3–98.8
|
126 (95.5)
|
90.2–98.0
|
|
|
Unknown
|
10 (4.0)
|
4 (3.4)
|
1.2–8.7
|
6 (4.6)
|
2.0–9.8
|
|
|
Number of perpetrator* (n = 251)
|
|
|
|
|
|
0.403[a]
|
|
1
|
107 (42.6)
|
54 (45.4)
|
36.6–54.5
|
53 (40.2)
|
32.0–48.8
|
|
|
2 or more
|
144 (57.4)
|
65 (54.6)
|
45.5–63.4
|
79 (59.8)
|
51.2–68.0
|
|
|
Alcohol use* (n = 161)
|
|
|
|
|
|
0.263[b]
|
|
No
|
147 (91.3)
|
67 (88.2)
|
78.5–93.8
|
80 (94.1)
|
86.4–97.6
|
|
|
Yes
|
14 (8.7)
|
9 (11.8)
|
6.1–21.5
|
5 (5.9)
|
2.4–13.6
|
|
Neglect was the most described typology (53.9%), the beating was the most common means
(33.9%), resulting in fractures in 31.5% of cases, and the axial axis was the most
affected anatomical segment (40.0%). Regarding the fracture site and sex of the victim,
fractures only in the axial skeleton were frequent in males, and fractures in two
or more segments predominated in females (p < 0,05). 15 of them (17.6%) required surgical intervention. There were five deaths:
two due to gunshot wounds, one due to beatings, one due to automobile accidents, and
one due to falls ([Table 3]).
Table 3
|
Variables
|
Total
|
Female
|
Male
|
p-value
|
|
n (%)
|
n (%)
|
CI95%
|
n (%)
|
CI95%
|
|
|
Type (n = 271)
|
|
|
|
|
|
0.352[
a
]
|
|
Negligence
|
146 (53.9)
|
61 (50.0)
|
41.1–58.9
|
85 (57.0)
|
48.9–64.8
|
|
|
Physics
|
106 (39.1)
|
50 (41.0)
|
32.5–50.0
|
56 (37.6)
|
30.1–45.7
|
|
|
Other**
|
19 (7.0)
|
11 (9.0)
|
5.0–15.7
|
8 (5.4)
|
2.7–10.4
|
|
|
Means/Instrument* (n = 248)
|
|
|
|
|
|
0.297[
b
]
|
|
Spanking
|
84 (33.9)
|
39 (34.8)
|
26.5–44.2
|
45 (33.1)
|
25.6–41.5
|
|
|
Traffic Accident
|
52 (21.0)
|
21 (18.8)
|
12.5–27.2
|
31 (22.8)
|
16.4–30.7
|
|
|
Electric Shock
|
33 (13.3)
|
14 (12.5)
|
7.5–20.1
|
19 (14.0)
|
9.0–21.0
|
|
|
Falls
|
32 (12.9)
|
20 (17.9)
|
11.7–26.2
|
12 (8.8)
|
5.0–15.0
|
|
|
Firearm
|
17 (6.9)
|
5 (4.5)
|
1.8–10.4
|
12 (8.8)
|
5.0–15.0
|
|
|
Other***
|
30 (12.1)
|
13 (11.6)
|
6.8–19.1
|
17 (12.5)
|
7.9–19.3
|
|
|
Presence of Fractures* (n = 270)
|
|
|
|
|
|
0.537[
a
]
|
|
No
|
185 (68.5)
|
88 (70.4)
|
61.7–77.8
|
97 (66.9)
|
58.7–74.1
|
|
|
Yes
|
85 (31.5)
|
37 (29.6)
|
22.2–38.3
|
48 (33.1)
|
25.8–41.2
|
|
|
Type of fracture* (n = 85)
|
|
|
|
|
|
0.017[a]
|
|
Upper Member(s) Only
|
15 (17.7)
|
8 (21.6)
|
10.8–38.5
|
7 (14.6)
|
6.9–28.2
|
|
|
Lower Member(s) Only
|
16 (18.8)
|
7 (18.9)
|
8.9–35.6
|
9 (18.8)
|
9.8–32.9
|
|
|
Axial Skeleton Only
|
34 (40.0)
|
8 (21.6)
|
10.8–38.5
|
26 (54.17)
|
39.6–68.0
|
|
|
In 2 or more segments
|
20 (23.5)
|
14 (37.8)
|
23.3–54.99
|
6 (12.5)
|
5.5–25.8
|
|
|
Orthopedic consultation
(n = 276)
|
|
|
|
|
|
0.024[a]
|
|
No
|
185 (67.0)
|
75 (60.0)
|
51.1–68.3
|
110 (72.9)
|
65.1–79.4
|
|
|
Yes
|
91 (33.0)
|
50 (40.0)
|
31.7–48.9
|
41 (27.2)
|
21.0–34.9
|
|
|
Surgery*(n = 276)
|
|
|
|
|
|
0.912[
a
]
|
|
No
|
261 (94.6)
|
118 (94.4)
|
88.6–97.3
|
143 (94.7)
|
89.7–97.3
|
|
|
Yes
|
15 (5.4)
|
7 (5.6)
|
2.7–11.4
|
8 (5.3)
|
2.7–10.3
|
|
|
Death*(n = 270)
|
|
|
|
|
|
0.380[
b
]
|
|
No
|
265 (98.1)
|
122 (99.2)
|
94.3–99.9
|
143 (97.3)
|
92.9–99.0
|
|
|
Yes
|
5 (1.9)
|
1 (0.8)
|
0.1–6.0
|
4 (2.7)
|
1.0–7.1
|
|
In the analysis adjusted for sex and age, age of the victim (less than two years)
(or 2.48; 95% CI: 1.45 - 4.25), involvement of two or more aggressors (or 2.09; 95%
CI: 1.16 - 3.75), the means being traffic/automobile accident, (or 2.65; 95% CI: 1.04–6.75),
presence of consultation with orthopedist (or 6.77; 95% CI: 3.66–12.51), and the need
for surgical intervention (or 36.72; 95% CI: 8.22–164.03) were statistically significantly
associated with increased risk of fractures ([Table 4]).
Table 4
|
Not adjusted
|
Adjusted for age and gender
|
|
Variables
|
CR (CI95%)
|
p-value
|
CR (CI95%)
|
p-value
|
|
Sex of the victim
(n = 270)
|
|
|
|
|
|
Female (125)
|
1
|
0.537
|
1
|
|
|
Male (145)
|
1.18 (0.70–1.97)
|
1.34 (0.79–2.29)
|
0.283
|
|
Age of victim
(n = 270)
|
|
|
|
|
|
≥ 2 years (82)
|
1
|
|
1
|
|
|
< 2 years (188)
|
2.37 (1.39–4.03)
|
0.001
|
2.48 (1.45–4.25)
|
0.001
|
|
Ethnicity
(n = 270)
|
|
|
|
|
|
Not white (41)
|
1
|
|
1
|
|
|
White (239)
|
1.52 (0.62–3.71)
|
0.356
|
1.33 (0.53–3.31)
|
0.542
|
|
Disability
(n = 195)
|
|
|
|
|
|
No (186)
|
1
|
|
1
|
|
|
Sim (9)
|
0.66 (0.13–3.29)
|
0.616
|
0.74 (0.14–3.81)
|
0.718
|
|
Municipality (n = 267)
|
|
|
|
|
|
Florianópolis (94)
|
1
|
|
1
|
|
|
Other** (173)
|
0.33 (0.44–1.32)
|
0.325
|
0.78 (0.44–1.38)
|
0.395
|
|
Gender of the perpetrator(s)* (n = 242)
|
|
|
|
|
|
Female (120)
|
1
|
|
1
|
|
|
Male (122)
|
1.17 (0.67–2.03)
|
0.589
|
1.20 (0.66–2.17)
|
0.554
|
|
Gender of the perpetrator(s)* (n = 242)
|
|
|
|
|
|
Female (53)
|
1
|
|
1
|
|
|
Both (135)
|
1.64 (0.80–3.37)
|
0.176
|
1.68 (0.80–3.52)
|
0.169
|
|
Male (54)
|
0.79 (0.32–1.96)
|
0.607
|
0.87 (0.34–2.25)
|
0,775
|
|
Number of perpetrator
(n = 251)
|
|
|
|
|
|
1 aggressor (107)
|
1
|
|
1
|
|
|
2 more aggressors (144)
|
2.14 (1.19–3.83)
|
0.011
|
2.09 (1.16–3.75)
|
0.014
|
|
Use of alcohol by the perpetrator (n= 161)
|
|
|
|
|
|
No (147)
|
1
|
|
1
|
|
|
Yes (14)
|
0.99 (0.29–3.33)
|
0.988
|
1.26 (0.36–4.40)
|
0.714
|
|
Bond with the victim
(n = 246)
|
|
|
|
|
|
Unknown (10)
|
1
|
|
1
|
|
|
Known (236)
|
1.72 (0.36–8.31)
|
0.499
|
1.61 (0.33–7.83)
|
0.554
|
|
Typology
(n = 265)
|
|
|
|
|
|
Other (18)
|
1
|
|
1
|
|
|
Negligence (145)
|
3.26 (0.72–14.81)
|
0.126
|
2.60 (0.56–12.02)
|
0.221
|
|
Physics (102)
|
4.95 (1.08–22.72)
|
0.040
|
3.67 (0.78–17.16)
|
0.099
|
|
Means (n = 248)
|
|
|
|
|
|
***Other (53)
|
1
|
|
1
|
|
|
Beating (79)
|
2.07 (0.87–4.92)
|
0.099
|
1.90 (0.78–4.60)
|
0.157
|
|
Traffic (51)
|
2.51 (0.99–6.30)
|
0.051
|
2.65 (1.04–6.75)
|
0.042
|
|
Shock (33)
|
0.13 (0.16–1.10)
|
0.061
|
0.13 (0.15–1.07)
|
0.057
|
|
Fall (32)
|
2.21 (0.79–6.19)
|
0.131
|
2.28 (0.78–6.57)
|
0.129
|
|
Orthopedic Consultation
(n = 270)
|
|
|
|
|
|
No (179)
|
1
|
|
1
|
|
|
Yes (91)
|
5.02 (2.88–8.73)
|
<0.001
|
6.77 (3.66–12.51)
|
<0.001
|
|
Surgical Intervention
(n = 270)
|
|
|
|
|
|
No (255)
|
1
|
|
1
|
|
|
Yes (15)
|
16.52 (3.63–75.05)
|
<0.001
|
36.72 (8.22–164.03)
|
<0.001
|
|
Development: Death (n= 266)
|
|
|
|
|
|
No (261)
|
1
|
|
1
|
|
|
Sim (5)
|
1.46 (0.24–8.88)
|
0.684
|
1.09 (0.17–6.95)
|
0.928
|
Discussion
Male victims, as noted in the literature,[12] were the most affected (54.7%), with a 1.2-fold risk of presenting associated fractures,
when compared to females.
The extremes of age (< 2 years and > 10 years) were the groups most likely to suffer
aggression. Infants (< 2 years) presented a 2.4 times higher risk of fractures when
compared to those older than two years, regardless of sex, corroborating the international
literature[6]
[7]
[19] and differing from that computed by Disque 100 (Dial 100), where school victims
were the most listed.[9] It should be noted that the smaller the child, the more dependent on care the child
is, including reaching a health service, with underreporting due to omission of care.[2]
In the southern region of the country, white ethnicity predominates,[8]
[26] explaining the disparity between reports of violence in people of this ethnicity
(89.4%) in relation to the others, different from the data of the Disque 100, which
indicates the brown population as the most affected by mistreatment, followed by white
and black.[9] In this study, having white skin color was associated with a 1.5 times higher risk
for fractures related to abuse when compared to other skin colors.
The presence of victims with disabilities was not significant (6.0%), diverging from
the literature,[1]
[2]
[7]
[9]
[15]
[19] leading to infer that the failure to seek emergency care for these patients could
be related to possible notification errors, the lack of diagnosis of aggression and/or
notification and the inability to verbalize victims with disabilities.[2]
[26] In this group, there was no association with fracture risk.
The greater number of notifications from other municipalities (65.2%) than the capital
can be justified because the hospital is large and a reference in orthopedics in the
State.
Regarding the authorship of the maltreatment, most had at least two aggressors, mainly
the father and mother, simultaneously, corroborating with the literature, which maintains
the pattern of parents as the main suspects of child maltreatment.[1]
[2]
[3]
[4]
[5]
[6]
[7]
[9]
[15]
[17]
[19] In 91.0% of the cases, the authors of the aggressions were not under suspicion of
alcohol use, in line with the literature,[2]
[9]
[15] there was no relationship between the use of alcohol by the aggressors and the outcome
fractures.
Corroborating national and international research,[2]
[3]
[4]
[5]
[6]
[12] neglect (53.9%) and physical aggression (39.1%) were the most prevalent typologies,
with similar distribution between genders. The high prevalence of the latter may be
related to the use of physical force as a form of “education” or disciplinary practice,[1]
[2]
[12] where parents who were raised through punishment and physical punishment perpetrate
this culturally accepted habit,[1]
[2] regardless of the existence of public policies, such as Law No. 13,010–“Lei do Menino
Bernardo” (Bernardo Boy Law)[27] or the Statute of the Child and Adolescent.[28]
The increased risk of these two forms of maltreatment in the occurrence of fractures
was 3.3 and 5.0 times higher, respectively, when compared to all the others studied.
Understanding the importance of vigilance of parents to their children and especially
continuing education about accidents and unintentional injuries.[2]
[3]
[7]
When the means of aggression were evaluated, “traffic accidents” and” beating” responded
to more than half of the notifications (54.9%), followed less expressively by electric
shock (13.3%), falls (12.9%), and “others,” similar to the literature,[2]
[6]
[7]
[9]
[19] signaling for the practice of physical force as an educational disciplinary measure[1]
[2]
[12] and the absence of observance of safe transportation.[2]
[29] “Beating” and “traffic accidents” were related to a 2.1-and 2.5-fold risk of causing
fractures.
The outcome “fractures” was 2.2 times more frequently observed in the “falls,” paying
attention to the need for surveillance and supervision, especially of minors who are
starting to walk.[2]
[3]
[7] Its prevalence (31.5%) was 4.5 times higher than in another national study.[15]
Regarding the anatomical location of the fractures, 40.0% were present only in the
axial skeleton, including the skull, a region related to a more severe outcome.[2]
[3]
[4]
[5]
[6]
[7]
[12]
[15]
[18]
[19] 23.5% of the victims presented injuries in more than one segment, being a risk factor
for mistreatment[2]
[3]
[4]
[5]
[6]
[7]
[11]
[18]
[19], that is, a child with multiple fractures, especially in more than one anatomical
site, should be evaluated more closely for this diagnostic suspicion.
Of the patients studied, regardless of gender, children under two years of age had
a 2.5 times higher risk of suffering fractures than other age groups, in addition
to a 1.7 times higher risk for the same outcome if the violence was perpetrated by
acquaintances when compared to those who were assaulted by strangers. Other factors
associated with a higher risk of fractures were aggression being committed by two
perpetrators or more, victims of automobile accidents, and care provided by an orthopedist—risks
respectively 2.1, 2.7, and 6.8 times higher. Considering that automobile accidents
are sometimes related to negligence, a great challenge emerges: Safe transportation
for children must be established in the safety rules for the transport of children
in vehicles.[29]
Fifteen patients (17.7%) underwent orthopedic surgery as part of the treatment, and
the presence of bone fracture was related to 16.5 times more need for surgical intervention
and 1.5 times the risk of death when compared to the absence of it in the study.
These data reinforce the importance of prevention,[2]
[29] of attention to the signs that may raise suspicions of mistreatment, and the appropriate
investigation by the “front line” professional and referral to the specialist when
appropriate.[6]
[7]
[19]
The secondary source of the data is cited as a probable limitation, which was resolved
by manually checking the notification forms one by one and checking the victim's hospital
records.
Conclusions
Due to the dependence and vulnerability inherent to the life cycle, children are a
risk group for various violence, whether accidental or intentional, requiring both
family education for prevention and the attention of the assistance professional in
the identification and correct notification of this aggravation, with adequate management
of cases, avoiding serious outcomes.
