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Skeletal Injury in Child Abuse Lori D. Frasier MD Professor of Pediatrics Penn State Hershey Children’s Hospital.

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Presentation on theme: "Skeletal Injury in Child Abuse Lori D. Frasier MD Professor of Pediatrics Penn State Hershey Children’s Hospital."— Presentation transcript:

1 Skeletal Injury in Child Abuse Lori D. Frasier MD Professor of Pediatrics Penn State Hershey Children’s Hospital

2 Fractures are a normal part of childhood and common in abuse l Up to 66% of boys and about 40% of girls will sustain a fracture by their 15 th birthday. l 85% of accidental fractures are seen in children over 5 years. l Fractures occur in 25% of abused children l 80% of abusive fractures are seen in children less than 18 months of age.

3 Child abuse fractures l Any bone can be fractured as a result of abuse. l Many abusive fractures in infants are not clinically obvious (rib and metaphyseal especially) l Associated bruising is rarely present over abusive fractures. l The highest incidence of abusive fractures are under 5 months of age.

4 Bones: Abusive Fractures l Type of fracture is important l Age and development of child l History is important and is often incompatible with history trauma l There may be evidence of abuse, other fractures

5 Skeletal Injury l Occurs in 11-55% of abused children l King, et al, J Pediatric Orthop. 1988; 8: 585-589 n 429 fractures in abused children u 76% in long bones u 8% in skull u 8% in rib cage

6 Distribution of Abusive Fractures Loder and Bookout, 1991 l 154 fractures in 75 abused children n 32% skull n 20% ribs n 45% long bone  28% “ corner fractures ”

7 Distribution of Abusive Fractures Worlock, et al 1986 l 156 fractures in 35 abused children n In children < 18 months: u 60% involved the ribs u 11% skull fractures n In children > 18 months: u No rib fractures u 40% skull fractures All CML ’ s <18 months

8 Distribution of Abusive Fractures Kleinman, et al 1995 l 165 inflicted fractures in 31 fatalities n 51% involved the rib cage n 44% long bone fractures u 89% Classic Metaphyseal Lesions (CMLs) n 5% long bone shaft fractures

9 Myths about fractures l Spiral fractures are nearly always abusive n Fact: Spiral fractures can be accidental if a twisting mechanism is implicated. l Babies bones break easily n Young infants have flexible bones that bend before they break l There should be bruises over inflicted fractures n Bruises over inflicted fractures are rare

10 Patterns of Skeletal Injury l Common, but low specificity n Subperiosteal new bone formation n Clavicular fractures n Long bone fractures except in non mobile infants Linear skull fractures,may be abuse if history doesn ’ t fit Kleinman: Diagnostic Imaging of Child Abuse, 2 nd Edition

11 Patterns of Skeletal Injury l Moderate Specificity n Multiple fractures n Fractures of different ages n Epiphyseal separations n Vertebral body fractures n Digital fractures n Complex skull fractures Kleinman: Diagnostic Imaging of Child Abuse, 2 nd Edition

12 Patterns of Skeletal Injury l High Specificity n Classic metaphyseal fractures n Rib fractures n Scapular fractures n Spinous process fractures n Sternal fractures Kleinman: Diagnostic Imaging of Child Abuse, 2 nd Edition

13 Rib fractures

14 Rib Fractures l Unusual in children, except in cases of abuse u May see in some metabolic disorders, premature infants, skeletal dysplasias, motor vehicle collisions u Rarely caused by CPR u Rarely caused by birth u Rarely caused by surgery l Locations u Typically posterior u Also lateral and anterior Healing clavicle Anterior rib

15 Rib Fractures l Clinical presentation u Rib fractures may be found as an incidental finding on chest radiographs u Usually children are asymptomatic u Often no bruising or swelling

16 Skeletal Injuries l Posterior rib fractures n from levering over transverse process of spinal vertebra

17 Skeletal Injuries l Rib Fractures (posterior) don ’ t occur from CPR n rare from birth

18 Skeletal Injuries l 3D reformatted CT

19 Metaphyseal Fractures (Classic Metaphyseal Lesion-CML l Series of microfractures oriented horizontally across the metaphysis (perpendicular to the long axis of the bone) l To-and-fro manipulation of the bone. l 39-50% of abused children n Distal femur n Proximal tibia n Distal tibia n Proximal Humerus

20 Classic Metaphyseal Lesions CML requires shearing forces not produced in accidental trauma Consider forceful twisting or traction Possibly produced during shaking where limbs flail about

21 Skeletal Injuries l Metaphyseal Fractures require “ non- accidental ” forces  Grabbing, twisting, shaking produce shear strains  Common in fatal abuse  Common in AHT

22 How the CML looks on xray depends on the plane of the xray beam

23 Metaphyseal Fractures l “Bucket handle” or “corner fractures”

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25 Fractures of the Diaphysis ( midshaft) l Less specific for abuse than metaphyseal fractures l Occur 4X more often in abused children

26 Types of long bone fractures l Spiral: requires a rotational or twisting force l Oblique: Combines loading a compressive forces with rotation (can look similar to spiral on xray) l Transverse Fracture: Bending or direct force n Displaced transverse fracture due to high energy blow l Greenstick (incomplete) l Torus (Buckle) Axial loading

27 Spiral fracture

28 Oblique fracture

29 Transverse Fractures Bending or direct force More energy than a spiral fracture

30 Transverse fracture with displacement

31 Greenstick or incomplete l Flexible bones in infants often break this way.

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33 Torus or “buckle” fracture l Axial loading-longitudinal compression l Any long bone

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35 Femur-Torus fracture

36 Torus fracture with healing

37 Bones fractured-femur l Femur: most common in abused and non abused children n Abusive femur fractures occur most often in children not yet walking

38 Tibia and fibula l Abusive fractures most common in non ambulatory infants l Toddler’s fracture: a stress fracture, usually accidental in children 9mo- 3y.

39 Toddler’s fracture

40 Humerus l Supracondylar: majority are accidental due to a fall l Spiral or oblique: in less than 5 years, commonly abusive, if no history

41 Acromion fracture- Spiral or possibly oblique humeral diaphyseal fracture

42 Humerus: healing transverse fracture

43 Radius/Ulna l 10-20% are from abuse l Mid diaphysis usually from abuse l Distal buckle fractures in mobile children usually accidental (FOOSH)

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45 Clavicle l Common birth injury l Common accidental injury in mobile children l Abusive fractures are often midshaft l Acute clavicle fractures in non mobile infants have a high specificity for abuse if there is no history

46 Hands and Feet l Feet fractures are uncommon and specific for abuse in young children l Likely due to direct trauma l Difficult to see radiology, may require multiple high resolution if suspected

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48 3D CT to define unusual fractures

49 Skull Fractures l Linear, parietal bone fractures u Most common type and location in both accidental and abusive head injury l Fractures caused by abuse constitute a minority of all pediatric skull fractures l Fracture which may be more suggestive of abuse u Multiple, bilateral and fractures that cross suture lines Hobbs and Meservy

50 l Linear parietal skull fracture with overlying swelling

51 Skull Fractures l May or may not have associated intracranial injury u Schutzman, 2001: the presence of a skull fracture is a positive predictor of intracranial injury l Most childhood fractures occur from short distance falls and are neurologically benign

52 Skull Fractures l Unlike skeletal injuries, skull fractures do not heal with the typical periosteal reaction and cannot reliably be dated l May or may not see overlying swelling u In some cases swelling is seen only at autopsy u This may be related to the hemodynamic compromise present in many of these children that have sustained massive head injuries

53 Imaging in skull fractures l Conventional radiographs are the gold standard; however being replaced by 3D reformat on CT u Should not be the primary imaging choice in children with suspected head injury u Often performed as part of the skeletal survey to demonstrate and document fractures u AP and lateral images are standard u Skull radiographs should be obtained in addition to bone scans which are relatively insensitive to detecting skull fractures

54 Complex Skull Fracture

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56 Differential Diagnosis l Most difficult to distinguish from non- accidental trauma n Skeletal injuries: u Accidental injury u Osteogenesis imperfecta  Menkes ’ Syndrome u Leukemia/Lymphoma  Caffey ’ s disease u Congenital syphilis u Rickets/scurvy/vitamin A intoxication

57 Rickets

58 Gracile or ribbon-like ribs seen in osteogenesis imperfecta with rib fractures

59 Osteogenesis Imperfecta

60 Rare, inherited disorder of connective tissue resulting from abnormal quantity or quality of type I collagen. Type I: 80% of cases, AD inheritance, milder form, blue sclerae, short stature, positive family history Type II: < 10% of cases, perinatally lethal Type III: rare and severe, AD or new mutation, fractures at birth in 2/3 Type IV: rare, sporadically occurs in 1 in 3 million births, AD inheritance, normal sclerae, may have normal looking bones, most likely to be confused with child abuse Types V-VII more newly identified

61 Bone Diseases which can “mimic” Abuse l Spina bifida/neuromuscular disease l Osteomyelitis l Congenital syphilis l Rickets l Scurvey l Vit. A intoxications Caffey ’ s disease l Leukemia l Copper deficiency Menke ’ s syndrome l Drugs n Prostaglandin E n Methotrexate l Metaphyseal and spondylometaphyseal dysplasias

62 Skeletal Survey l Performed in all infants and young children with suspected abuse less than 2 years. l Children greater than 5 years rarely have skeletal injuries related to abuse. l Children in the 2-5 year range are imaged on a case-to-case basis. “ The ‘ body gram ’ (a study that encompasses the entire infant or young child on 1 or 2 radiographic exposures) or abbreviated skeletal surveys have no role in the imaging of these subtle but highly specific bony abnormalities ” American Academy of Pediatrics statement on diagnostic imaging of child abuse (Pediatrics Vol.105 No.6 June 2000)

63 American College of Radiology l ACR Standards suggest a minimum of 19 images to include a separate exposure of each anatomic location u AP and lateral views of the axial skeleton u Frontal views of the extremities u Additional views may be necessary to confirm or document suspicious sites of injury-radiologist must review before child leaves the suite u Most centers have added two views R and L obliques of the chest

64 Oblique

65 No Babygrams

66 Dating Fractures l Radiological- n less than a few days may not be visible n Subperiosteal new bone is apparent on xray at about 7-10 days n Callous can be visible for several months l Histologically--autopsy may be more precise in dating l Clinical--Use of arm, bearing wt, irritability may help define when the injury occurred

67 Fracture Healing l Periosteal new bone n 10-14 days l Visible callus n 2-4 weeks l Incomplete bridging n 3 weeks l Complete bridging n 10 weeks Infants heal more rapidly but good data is not available.

68 Follow-up Skeletal Surveys l Follow-up skeletal survey in 10-14 days to look for additional sites of injury that may not be seen on initial study u Skull films are not repeated u Nuclear Bone scan can also be considered but has some limitations. (ie skull and metaphyses especially) u May be especially helpful in ribs and CMLs

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71 Nuclear Medicine Bone Scans l May be used to clarify fractures n Ribs n Long bones l Not useful for: n Skull n Metaphyseal l Requires sedation l Maybe more radiation that a well- done skeletal survey

72 Rib Fractures- NM bone scan can be helpful

73 Siblings l Twins or multiples must have skeletal surveys if sibling has suspicious injuries l Siblings less than two in same environment skeletal survey is recommended l Older siblings not recommended

74 Recommended non radiology work up l Comprehensive metabolic panel (will include Calcium, phosphorus, alkaline phosphatase l 25-0H Vitamin D l Possibly PTH if signs of bone turnover or high alkaline phosphatase l Referral to genetics if concern regarding OI l DEXA scans (bone density, speed of sound) have no role in the evaluation of infant fractures


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