Bones, Breaks, and the Battered Child: Is It Unintentional or Is It Abuse?
Authors: Robert M. Sills, DO, FAAP, Director Pediatric Emergency Medicine, Department of Emergency Medicine, St. John’s Hospital and Medical Center, Detroit, MI; Margarita E. Pena, MD, FACEP, Clinical Instructor, Emergency Medicine, Department of Emergency Medicine, St. John’s Hospital and Medical Center, Detroit, MI; Kenneth Parsons, MD, MPH, Resident, Emergency Medicine, Department of Emergency Medicine, St. John’s Hospital and Medical Center, Detroit, MI.
Peer Reviewer: Steven Winograd, MD, FACEP, Attending Physician, Department of Emergency Medicine, Lakeland Regional Health System, St. Joseph, MI.
Acute musculoskeletal injury accounts for a large percentage of all visits to the ED. Although fairly straightforward in adults, managing these injuries in children presents special challenges. The clinician must keep in mind that fracture patterns can often be different in children, various growth centers in the bones can simulate fractures, the history is often given by a caretaker and not the injured child, and the physical exam is often more difficult to perform on a child. In addition, it is important to keep in mind that any injury presenting to the ED may be the result of child abuse. The reported frequency of fractures associated with child abuse varies from 11-55%.1 To effectively manage these injuries, one must develop a systematic approach to evaluating the injured child. This approach must include a thorough history and physical, an understanding of the types of injuries children can sustain, a basic knowledge of pediatric radiographs, and, most importantly, an understanding of how to diagnose and manage the intentionally injured (or abused) child. A discussion of the definitive treatment of pediatric fractures can be found in most pediatric, emergency and orthopedic textbooks and will not be emphasized here. The authors will review skeletal injuries in children with an emphasis on the evaluation and initial treatment of the abused child.
It is well known that commonly occurring childhood fractures (e.g., femur fractures) can be the result of abuse, and that fractures that raise the suspicion of abuse (e.g., spiral fractures) can be accidental.2,3,4 Therein lies the rift. This article will review the pathophysiology and types of common childhood fractures, and will aid the clinician in deciding which injuries are abusive and which are not. Keep in mind that there is a vast gray area in which the determination is difficult to make. In these cases, experts in this area (i.e., child maltreatment specialists, social service personnel, and pediatric orthopedic surgeons) can assist in making the determination.
The Editor
Child Abuse
There are many ways to define child abuse. A practical definition of physical abuse for the clinician is: "An injury to a child caused by a caretaker for any reason . . . Injury includes tissue damage beyond erythema or redness from a slap to any area other than the hand or buttocks. Physical discipline should not be used on children who are under 12 months of age. The child should be normal developmentally, emotionally, and physically. Tissue damage includes bruises, burns, tears, punctures, fractures, rupture of organs, and disruption of functions. The use of an instrument on any part of the body is abuse. The injury may be caused by impact, penetration, heat, a caustic, a chemical, or a drug."5 This is not only a thorough definition, but it can aid the clinician in defining which injuries are considered beyond accepted disciplinary measures.
The prevalence of child maltreatment, in all forms, continues to rise. Compared to younger children, children older than 3 years of age are much more likely to suffer physical and sexual abuse.6 However, life-threatening injuries and fractures secondary to abuse are much more common in children younger than 5 years of age, with 80% of abuse fractures occurring in this age group.1,8 In fact, age is the single most important risk factor in the increase of abuse-related skeletal injuries.1 These are, unfortunately, the patients in whose history is most difficult to obtain, and a physical exam harder to perform.
It is important to remember that physical abuse occurs throughout all strata of society and not just in the indigent population.6 Many of the pitfalls that occur in diagnosing abuse deal with health care professionals’ personal beliefs and experiences. Physicians tend to believe that abuse does not occur in pleasant, well-spoken, and well-dressed families. Don’t be fooledall patients should be treated and evaluated with the same systematic approach to avoid missing the diagnosis of child abuse.
Multiple social and cultural factors and family stresses contribute to a child’s risk for abuse. Some of the more important risk factors include: the child who is perceived as different (i.e., such as the child with mental or physical handicaps, or behavioral problems); social stressors, such as poverty, unemployment, poor family support, or poor parental relationship; and/or parent produced stresses, such as low self-esteem, being a product of an abusive parent, depression, substance abuse, or ignorance of child rearing. Child abuse can occur when a triggering event, such as a family conflict or substance abuse, is associated with any or all of the above risk factors.7
The Growing Bones
The bones of a child need to be able to grow with the child. There are special features of the young bone that allow this to happen. (See Figure 1.) A typical long bone allows growth by having growth centers that consist of four distinct anatomic regions. The first region, the metaphysis, is a flared out area between the shaft and the physis. The second region, the physis, is a cartilaginous growth area consisting of several zones. In the physis, a matrix upon which new bone is formed is produced. When the bone stops growing, this cartilaginous area becomes filled with bone. The third region is the epiphysis, which is the bony plate atop the physis that serves as a support for the articular cartilage of that bone. If the end of the bone does not form a joint but attaches to muscles or tendons, it is called an apophysis. Finally, the diaphysis is the shaft of a long bone. Any injury to the growth plate can arrest growth and, subsequently, result in limb deformities. The physis is relatively weak compared to the strong ligamentous attachments between the bones and, when injured, will usually result in a fracture rather than a sprain. Therefore, as a general rule, younger children are more likely to break their bones than have sprains.9
A growing child’s bones are less dense and have more cartilaginous features than the bones of an adult. The periosteum of a young bone is thicker and has more bone-forming potential than its adult counterpart. These characteristics of the periosteum allow far less displacement of the fracture fragment and quicker healing. Another important feature of the young bone is its ability to remodel. Because of its rapid active growth, the young bone can overcome many imperfections in alignment depending on the location and type of fracture.9,11 Because of the unique features of the young bone, there are specific fractures that occur in children that do not exist in adults. (See Figure 2.) A Buckle or Torus fracture occurs when a compressive force results in failure of the bone, usually at the metaphyseal-diaphyseal junction of the radius or tibia. These fractures can be very subtle both clinically and radiographically. This type of injury occurs in the long bones, which is uncommon in abuse situations. A plastic deformity or bowing fracture occurs when the bone is bent beyond its ability to recoil and remains in a bowed or curved position. Presentation of plastic deformity on x-rays are often subtle. In this situation, comparison films with the normal extremity are beneficial. Greenstick fractures also occur because of the decreased density of the younger bone, resulting in an incomplete fracture involving only one cortex. They are often associated with a bowing deformity. Growth plate fractures involve the physis and/or the metaphysis and epiphysis. They occur in growing bones and can affect subsequent growth. The Salter-Harris classification system is used to describe the five most common injuries to the growth plate. The higher the number type, the greater likelihood of long-term effect on bone growth. (See Figure 3.)9,10,11
Other common fracture patterns in childhood, include longitudinal, transverse, oblique, spiral, and comminuted fractures.9,10,11 All of the previously mentioned fractures can occur in child abuse. However, some are more common than others.
History
In all injuries to children, a thorough history and physical must be obtained to avoid missing the diagnosis of abuse. When evaluating the injured child, it is important to have a complete understanding of the events surrounding the injury. The history can be supplied by the child (if verbal), the parent, or other witnesses. When possible, it should be substantiated by as many witnesses as possible. It is important to ask open-ended questions. Asking the patient, "Why are you here today?" or "What happened to you?" may give a more complete representation of the events rather than a yes or no question, such as "Did your brother push you?" Let the historian supply as much information as possible without leading them. The information should be detailed and include such questions as, what happened, when, where, who was present, and how did it happen? The history should also include previous injuries, fractures, lacerations, burns, hospitalizations, and any significant past or present history of disease processes (i.e., hemophilia, cerebral palsy, failure to thrive, and osteogenesis imperfecta). Injuries not consistent with the history should raise the suspicion of abuse. Injury should be considered in the context of normal developmental milestones. (See Table 1.) A pre-ambulatory 7-month-old child, for instance, should not sustain a femur fracture by walking and then falling, nor should a fall from a crib produce multiple fractures or serious injury. The history of the event should be precise and any inconsistencies should be documented. Suspicious histories are usually vague and in two studies were more likely to involve a change in behavior (i.e., child is irritable or not moving an extremity) or a noted abnormality (i.e., swelling of the skull) rather than a history of actual trauma.3,4 In fact, 63% of abused children in one study and 52% in another who had fractures related to abuse had no history of trauma.
A common type of history given in both abusive and unintentional injuries is a fall. A history of a fracture in a minor fall should be investigated, but single unintentional fractures can occur from falls of less than two feet, and falls from less than four feet can result in injury to more than one bone.3 Changing stories with repeated histories should also raise suspicion. It is usually best to question the child and the caregiver separately about the events. The child may feel safe in the company of a compassionate health care worker and may be more likely to supply pertinent information than in the presence of a threatening caregiver. Remember, the purpose of the interview in the ED is not to place blame on a specific person but to discover the details of the event. The detective work needed to find the culprit should be left to police investigators. The physician should be a family advocate, as well as a patient advocate. It is best to remain as neutral and objective as possible and assure the family that your ultimate goal is to ensure the safety of the child and not break up the family unit.
Physical Exam
In order to obtain an informative and complete physical exam on an injured child, it should be performed in a gentle and nonthreatening manner. To gain the child’s trust, examine the obviously injured area last and inform the child of each step of the exam. Distractions, such as toys, may help the examiner pinpoint the painful area. Observe first, then palpate. If a child is extremely anxious, he or she may let the parent do the exam. This may help in deciding which films to order. Remember that all injuries can be the result of abuse, and it is important that a complete head-to-toe exam be performed. Undress all areas at some point during the exam. Attention should be paid to the child’s modesty. Look for multiple injuries in different stages of healing (pathognomonic for child abuse).1 Areas often missed on physical exam that are frequently injured in the abused child include the buttocks, genital region, behind the ears, the scalp, the hands, and the feet. Perform the exam in a well lit area to detect subtle bruises and texture changes that may be difficult to discern in darker skinned patients.15 When examining the injured part of the body, perform a thorough exam including evaluation of neurovascular and motor function as well as inspection, palpitation, color, and temperature assessment.
Physical signs of neglect, which may add evidence to your suspicion of abuse, are easily missed. These signs include, but are not limited to, a dirty, unkempt appearance, severe diaper rash (from infrequent diaper changes), bald spots to the scalp, a withdrawn or shy child, and failure to thrive.
Radiographic Evaluation
Plain films are an important part of the investigation of an injured child. Most fractures can be picked up with two views of the bone at 90° to each other. Insist on perfect postero-anterior (PA) and lateral films. Oblique views are rarely indicated in long bone injuries except in cases where a clinically obvious fracture is not seen on the PA and lateral view.12 Oblique films are routinely indicated when the hand or foot are injured to avoid missing fractures. Multiple growth areas that change in appearance with age can be confused with fractures, and having a book of normal x-ray variants nearby is helpful. Although comparison views of the unaffected extremity may help in certain cases, routine comparison films are costly and may not be required.
When child abuse is strongly suspected in young children, an additional series of plain films can be helpful in the abuse work-up. Finding multiple fractures in different stages of healing is a classic finding in child abuse.1 A skeletal survey may pick up these older fractures. The skeletal survey includes two views of the skull, spine, and chest, and one view of the rest of the skeleton and has been shown to aid in the diagnosis of abuse in up to 31% of selected patients.3 A routine skeletal survey is indicated in all infants younger than 2 years of age who have clinical evidence of physical abuse, and in infants younger than 1 year of age who show evidence of significant neglect and deprivation. A selective approach to complete skeletal examination is suggested for older infants and children to age 5 years. Thereafter, a skeletal survey is rarely indicated.13 Follow-up skeletal surveys are suggested if abuse is strongly suspected. These follow-up surveys yielded additional fracture information in 61% of cases. Most were previously undetected metaphyseal-epiphyseal lesions.14 Follow-up skeletal surveys done approximately two weeks after the initial survey are suggested if abuse is strongly suspected.
Although classic x-ray findings exist that are diagnostic for abuse, these findings are often absent and the diagnosis must be made on history and physical alone. Multiple fractures in different stages of healing, fractures not consistent with the patientdevelopmental level, metaphyseal-epiphyseal fractures, and posterior rib fractures in an infant, are all consistent, if not diagnostic, for child abuse.1
Fractures of the long bones in children are common. Distinguishing between intentional and unintentional injuries to the long bones can be a challenge. Abuse fractures are typically divided into diaphyseal and metaphyseal-epiphyseal fractures. Abused infants are more likely to have metaphyseal-epiphyseal injuries than are older children. Abused children greater than 1 year of age are more likely to have diaphyseal fractures.19
Metaphyseal-Epiphyseal Fractures
Metaphyseal-epiphyseal injuries are classic fractures of child abuse and can occur in any long bone adjacent to a growth plate.15,18 The intensity and direction of force needed to cause this injury do not occur in typical "accidents." Although previously thought to be due to an avulsion of a metaphyseal fragment at the site of fixed periosteal attachment, it is now known that a different mechanism is involved.19 Shaking and jerking associated with large accelerating-decelerating forces cause a shearing effect that results in a fracture through the weak spongiosum bone layer. Depending on the size of the injury, the degree of involvement of the periphery of the bone, and the radiographic projection, the following lesions may result: the bucket handle fracture, the corner fracture, or the metaphyseal lucency.19 (See Figure 4.) In contrast, spurring and cupping of the metaphysis of the long bones are common, normal variants in infants under 8 months of age.11
Diaphyseal Fractures
Although much more common in abuse than metaphyseal-epiphyseal fractures, diaphyseal injuries are much less specific for abuse.2 Isolated diaphyseal fractures can present the most difficulty in making the diagnosis of abuse. Since no diaphyseal fracture in and of itself is pathognomonic for abuse, the clinician must take into account the history and physical, developmental age of the child, skeletal survey, social service report (if indicated), and the appearance of fracture. Even with all of this information, it can be difficult to determine how the fracture occurred.
Diaphyseal fractures including transverse, greenstick, spiral, oblique, and comminuted can occur in both intentional and unintentional injuries.2,4,20 However, the injury should be considered abusive when occurring in conjunction with other skeletal or extraskeletal injuries as well as in cases without adequate history. Long-bone fractures from abuse are more likely to occur in the middle and distal third of the bone.2,4 Spiral fractures of the femur, although classically considered abusive, can occur in a child who is running then trips and falls.4 However diaphyseal fractures in nonambulatory children should be considered highly suspicious.2,4
Dating Fractures
Although not an exact science, the physician should have an idea of how fractures appear in different stages of healing on plain films. Immediately after the injury, soft-tissue swelling and inflammation are apparent up until about four days following the injury.15 Periosteal reaction usually takes approximately 7-10 days to become apparent.1,16 Hard callus formation usually occurs 14-21 days after the injury.1 In infants and children, the fracture site can appear normal in as early as six months.15 Periosteal reaction can be physiologic in infants between 1 and 6 months because of the active growth occurring at this time and should not be mistaken as a fracture. It is more likely to be bilateral and involve the diaphysis of long bones.16
Regional Injuries
Skull. Skull fractures are the second most common bony injury seen in child abuse.13,15,21 The mechanism of injury is a forceful direct impact against a flat surface or from an object or fist. Of intentional skull fractures, 80% occur in infants younger than 1 year of age.1 The prevalence of skull fractures in abused infants is almost 50%. Infants have a six-fold greater risk of sustaining a skull fracture than an older child.17,2,21
The majority of abusive skull fractures are linear, nondepressed parietal fractures. Interestingly, linear parietal fractures are most common whether unintentional or secondary to abuse. Linear skull fractures can be seen in accidental falls less than two feet, and falls from less than four feet can result in complicated fractures. However, fractures that are multiple, depressed, diastatic more than 3 mm, bilateral, or cross suture lines are more suggestive of intentional injury, especially coupled with a suspicious history.3,22,28,29
Plain radiographs of the frontal and lateral views of the skull are the best initial screening modality for the skull, except for basilar skull fractures, which usually require computed tomography (CT) for detection. Cranial CT with bony windows are helpful in visualizing the extent of injury of depressed and complicated fractures as well as associated intracranial injuries. Radionuclide skeletal scintigraphy has a low sensitivity for detecting skull fractures.13
Humerus. The humerus is the most commonly fractured bone in battered children.2,20 Several authors have reports that the majority (46-81% in 5 different studies) of humerus fractures in children younger than 3 years of age are intentional, and in infants younger than 15 months, 67-100% of humerus fractures are thought to be secondary to abuse.4,3,22,25,26 Strait et al studied 164 humeral fractures, more than in any other series, in children younger than 3 years of age and used strict abuse criteria and excluding children with known abuse prior to discovery of the humeral fracture.20 In this study, only 8% of fractures under age 3 and 36% under 15 months were due to abuse. These significantly lower percentages may have resulted from excluding known abuse cases, thereby underestimating the percent due to abuse.
The most common fracture types associated with abuse are spiral/oblique and transverse.20,2 The most common fracture locations are midshaft or metaphyseal. Rotational or twisting injuries result in spiral/oblique fractures, while metaphyseal-epiphyseal injuries occur with tractional forces or when the child is grabbed by the arms or shaken.3,4
Classic metaphyseal lesions (CML) have been used to describe the metaphyseal-epiphyseal injuries seen in abuse. CML of the humerus are seen radiographically as lateral corner fractures, metaphyseal radiolucencies and irregularities, a discrete fracture line, or flame-shaped metaphyseal extensions.27 Subperiosteal new bone formation may also be seen. These radiographic changes are most evident in healing or chronic injuries. Acute injuries may have no radiographic signs of injury. Therefore, repeat and/or high-detail radiographs should be performed if abuse is suspected. These lesions are most evident with the humerus in external rotation, as is seen in a standard antero-posterior chest view.
Salter-Harris type fractures (i.e., distal physeal fractures) are less commonly seen than CML injuries and are the result of violent traction or twisting of the arm associated with a greater magnitude of force than seen with CML injuries.13,12 Abuse should be strongly considered when these injuries are present. Although plain radiographs are not very sensitive in detecting these injuries because of the nonossified epiphysis, there are some characteristic findings of these distal physeal fractures. The radius and ulna are displaced posteromedially relative to the distal humerus, there is displacement of the medial epicondyle or capitellar ossification center, and a distal humeral metaphyseal fragment may also be present.13 Without a history of birth trauma, distal physeal fractures are almost always secondary to abuse.29 Distal physeal injuries can easily be confused with supracondylar fractures or elbow dislocations on plain radiographs, both of which are not commonly associated with abuse. Ultrasound, magnetic resonance imaging, and arthrography can be useful in identifying these injuries as well as guiding orthopedic management by determining Salter type and therefore management type in order to prevent complications of inadequate reduction such as cubitus valgus and varus.
Supracondylar fractures, a common childhood fracture, are almost always accidental and are consistent with a history of an ambulatory child falling on an outstretched dorsiflexed hand with the elbow hyperextended or directly on a flexed elbow.29 Although, previously, these fractures had always been thought not to be associated with abuse, Strait et al found that supracondylar fractures were secondary to abuse in 20% of children less than 15 months of age. In this age group, greater consideration of the reported mechanism of injury and time of presentation may be warranted. Accidental proximal humeral fractures may be the result of birth trauma, direct impact to the posterolateral aspect of the shoulder, or a fall backwards onto an outstretched dorsiflexed hand with the elbow extended. Accidental humeral shaft fractures are rare and seen as a result of a direct impact or falling on an outstretched arm.
Radius and Ulna. Fractures of the radius and ulna represent 10-20% of all bony injuries from child abuse. Diaphyseal fractures can be seen in abuse and are usually transverse due to the same mechanism as "nightstick" fractures (i.e., blocking injuries of direct impact to the forearm). Most metaphyseal-epiphyseal injuries are distal and present as corner fractures or metaphyseal lucencies.15
The distal radius, overall, is the most commonly fractured long bone in children. Most accidental fractures are greenstick or torus fractures and result from a fall on an outstretched hand. Physeal fractures of the distal radius and ulna are most commonly Salter-Harris type I or II. Torus fractures are not commonly abusive. Physeal fractures, therefore, can be seen both in accidental and nonaccidental trauma. A compatible history in an ambulatory child would reflect an accidental injury whereas physeal injuries in nonambulatory infants would be much more suggestive of abuse.
Ribs. Rib fractures are seen in 5-26% of abused children with 90% of abuse-related fractures occurring in children under 2 years of age.11,21 In infants, rib fractures represent the most frequent fracture of abuse.22,31 In general, rib fractures in children are much less common than in adults owing to their more compliant chest walls. Therefore, rib fractures, especially multiple fractures or fracture of the first rib, are almost pathognomonic for abuse in children younger than 2 years of age in the absence of major blunt trauma or prior bone pathology.15,32
Fractures occur when the infant is manually grabbed around the thoracic cage and violently squeezed and shaken. (See Figure 5.) This anteroposterior compressive force results most frequently in multiple, symmetrical, posterior rib fractures where mechanical stress is at its greatest. With increasing force, lateral then anterior fractures occur.13 This mechanism of injury usually does not present with overlying bruising. Rib fractures resulting from direct blows to the chest, seen most often in children older than 2 years of age, are often associated with an overlying bruise.15 Of importance, rib fractures from cardiopulmonary resuscitation are rare in infants and young children.33
Acute rib fractures are very difficult to detect radiographically because of location, age, and orientation of the fracture line or fragment. A postmortem study of 31 abused infants showed that only 36% (30/84) of rib fractures were seen on skeletal survey even though most were healed fractures.17 A subtle radiographic sign of an early healing fracture is an extrapleural opacity corresponding histologically to organizing hematoma and cartilaginous callus. Signs of further healing include bony callus formation seen after two weeks, new subperiosteal bone formation, and a "hole in the rib" appearance resulting from bone resorption at the fracture line with surrounding new bone formation. Costochondral junction fractures involve the osteochondral junction, and as in CML seen in long bones, a radiolucency extending into primary spongiosa can be seen. Radiographs with high detail and oblique views are best for detection of rib fractures. Highly sensitive bone scans are useful for hard to see costovertebral rib fractures as well as other acute, nondisplaced fractures.
Pelvis. Mention of pelvic fractures due to non accidental trauma in child abuse literature is rare. Since non accidental femoral fractures are much more frequently seen in abuse, it has been suggested that careful evaluation of the adjacent pelvis for fractures would be prudent.15
Femur. Femur fractures are very commonly seen in battered children. In infants younger than 1 year of age, 60% are intentional.2,4 Oblique/spiral femur fractures in nonambulatory children should arouse a high suspicion of abuse. A history of a fall from less than three feet should also arouse suspicion, as midshaft fractures are unlikely to result from this height.35 The amount of force required to cause a midshaft femur fracture in an infant is substantial and requires a major acceleration-deceleration injury. Accidental fractures of the femoral shaft can be the result of a running fall with twisting injury in young ambulatory children.29
According to several studies, there is no one fracture type that is characteristic of abuse,4,36 although shaft fractures are more common than metaphyseal-epiphyseal fractures in abused children.2,15 In the study by Kleinman et al of 31 postmortem infants younger than 1 year of age, they found that the vast majority of femoral fractures (15/17) are metaphyseal-epiphyseal fractures, and all of these fractures involved the distal growth plate. This propensity for distal involvement is seen in abused children of all ages with bilateral involvement often associated with violent shaking.34 Proximal metaphyseal-epiphyseal injuries are difficult to visualize radiographically because of the multiple growth plates in this region that are initially nonossified. Subtle radiographic findings include soft tissue injury or abnormal alignment of the shaft relative to the pelvis. Although less common, it is important to identify them early since they can result in greater long-term sequelae such as avascular necrosis, nonunion, or growth disturbances. Bone scans, MRI, or arthrography are very useful modalities for detecting these subtle injuries.11,15
Tibia and Fibula. The tibia is a very common site for the CML17,2 with proximal growth plate involvement more common than distal.23 In a study using specimen radiology and histology of tibial fractures in abused children, Kleinman and Marks, describing CML, found that the medial margin of all proximal tibial fractures were involved.23 They hypothesized that anatomically the subperiosteal bone collar is not continuous with cortex at the medial metaphyseal margin of the proximal tibia as this is where remodeling occurs. This exposes medullary trabeculae, and therefore the bone is less dense than the lateral margin where subperiosteal bone is continuous with cortex. It is thought that this medial margin is more susceptible to the various mechanical forces involved in abuse. Involvement of the lateral metaphysis is seen in more significant injury but always concurrently with medial metaphyseal involvement.
The proximal tibial CML may have several appearances radiologically. The fracture line first undercuts a thick posteromedial metaphyseal bony fragment, then the classic corner fracture is seen on the AP view. The bucket handle appearance, better seen using a beam with caudal angulation, is just an extension of this fracture line anterolaterally and may involve the tibial tubercle region. The most subtle finding of an acute fracture is a radiolucent line extending laterally from the medial metaphyseal margin and is referred to as a metaphyseal lucency. Similar radiographic findings are seen with distal growth plate fractures.
Non accidental injury should be strongly suspected in infants younger than 9 months with diaphyseal tibial fractures. Direct impact injury or violent grabbing and twisting can produce transverse and spiral/oblique fractures, respectively. Fracture lines are not always seen, but periosteal reaction with healing can commonly be seen. Unintentional oblique/spiral fractures of the tibia (toddler’s fracture), however, can be seen in novice walkers younger than 3-4 years of age.11,34
Fibular fractures secondary to abuse are rare, but, when they occur, they are from direct blows to the shaft seen concurrently with tibial shaft fractures.
Spine. Skeletal injury to the spine is not commonly seen in battered children. However, in infants without a history of trauma, any vertebral fracture should raise suspicion for abuse, as half of intentional spine injuries are seen in infants younger than 1 year of age.15 Most of these injuries are asymptomatic but commonly result in persistent vertebral body deformities and may present years later with a severe kyphosis or growth disturbance.37
Most intentional fractures involve the vertebral bodies of the thoracolumbar spine and are caused by severe hyperflexion-hyperextension associated with violent shaking or direct blows. Violent shaking of an infant also results in spinous process avulsion and interspinous ligament disruption. (See Figure 6.) Initial radiographs are usually negative because of the cartilaginous nature of the spinous processes in early infancy. Subsequent radiographs may prove useful in demonstrating signs of healing. Irregularly shaped spinous processes with adjacent ossification corresponding to ossification of the avulsed cartilaginous part of the spinous process and/or adjacent soft tissues may be seen.13,15
Anterior compression fractures from the hyperflexion aspect of shaking are most common in the lower thoracic and upper lumbar regions. These present radiographically as loss of bone or sclerosis of the fracture line on the anterosuperior or less commonly anteroinferior margin of the vertebral body.13,15 Spinous processes avulsions (clay-shoveler fractures) of the lower cervical or upper thoracic region can also be seen with intentional hyperflexion injury and are most commonly found in older children.38 Anterior or posterior and, less commonly, lateral subluxation may also be seen in child abuse and is best seen on lateral spine radiographs. Fracture dislocations of the cervical or lumbar spine from abuse have been reported but are rare.39
Accidental spine fractures in older children are rare and predominantly caused by falls, motor vehicle accidents (MVA), or sports/recreational activities in older children. Most cervical spine injuries in children involve the upper cervical region above C3. Odontoid fractures are among the most common types and can result from trivial head trauma.9 Children with Down’s syndrome are at risk for chronic atlantoaxial and atlantooccipital instability. Significant displacement with neurologic compromise can occur with relatively minor trauma from activities involving significant neck flexion such as somersaults or contact sports. Chronic atlantoaxial instability is also seen in children with juvenile rheumatoid arthritis, Reiter’s syndrome, Larsen’s syndrome, and bone dysplasias.9 Pseudosubluxation of C2-C3 is common in children and should not be confused with an acute injury. Pseudosubluxation of C3-C4 can also occur, but less frequently, and is seen mostly in younger children. Spinal fractures secondary to forward flexion over a lap-belt during an MVA can result in Chance Fractures usually involving L1-L4.9 These fractures consist of anterior compression fractures with distraction of the posterior vertebral elements.
Plain radiographs remain the best modality for detection of spine injuries due to abuse. Bone scintigraphy is useful in detecting subtle fractures of the transverse and spinous processes. However, it has poor sensitivity for detection of vertebral body fractures.
Shoulder Girdle. The clavicle is the most commonly fractured bone in children.11 Midshaft fractures of the clavicle are typically accidental and consistent with a history of an ambulatory child falling on his or her shoulder or outstretched arm or a newborn child with a history of a traumatic birth.1,15 Fractures seen two weeks after birth, with no callous formations, suggest the fracture did not occur at delivery.40 A suspicious history or a delay in seeking care may be the only clues to a non accidental midshaft clavicular fracture. Intentional clavicular fractures are uncommon. One large series found that clavicular fractures represent only 7% of all skeletal injuries in child abuse.21 Lateral or medial avulsion fractures of the clavicle result from violent shaking or arm traction and are much more specific for abuse.13 Associated proximal humeral injury may be seen with clavicular avulsion fractures.5
Accidental scapular fractures in children are rare and result from severe direct trauma such as an MVA or fall from a great height. Without this type of history, any scapular fracture should raise high suspicion for abuse. Non accidental avulsion fractures of the acromion process or, less commonly, fractures of the coracoid process are due to violent arm traction or shaking. Glenoid fractures and fractures to the body of the scapula from direct blows are rare fractures of abuse.15,21
Plain radiographs are best for evaluating fractures of the shoulder girdle. Bone scans may be helpful for the more subtle scapular fracture.15
Hands And Feet. Hand or foot fractures are not common fractures of abuse, but when they occur they are usually seen in older children. Both metaphyseal-epiphyseal and shaft fractures can be seen in abuse. Injuries are usually seen in the metacarpal or metatarsal areas and frequently involve multiple digits as the result of direct blows with an object or deliberate stomping.15
Accidental fractures of the distal metacarpals, especially the fifth (boxer’s fracture), are usually seen in adolescent males as a result of striking a person or object with a closed fist.29
Diseases Mistaken for Child Abuse
Making the diagnosis of child abuse is challenging and requires that the history, clinical, radiographic, and laboratory findings are all taken into account to responsibly suspect such an action has taken place. Though unavoidable, an incorrect diagnosis can be devastating not only to the caregivers but the child as well. Physicians must become astutely aware of and familiar with the variety of conditions that are commonly mistaken for child abuse.
Osteogenesis imperfecta (OI) is a skeletal disorder resulting from increased breakdown and/or reduced production of bone. There are four major categories with subtypes that can be inherited as an autosomal dominant trait or from spontaneous mutation.42 It is the most prevalent of the OI syndromes in childhood and is characterized by fractures and skeletal deformities that have been mistaken for abuse.43 Type I OI is the most common, with a frequency of approximately one in 30,000 births representing 80% of known cases.42 It is characterized by osteoporosis, excessive bone fragility, joint laxity, distinct blue sclera, and possible subsequent hearing loss.42 Nearly two-thirds will develop yellow-brown or gray discoloration with enamel fractures of their front incisors known as dentinogenesis imperfecta.44
Type II OI affect 1 in 60,000 live births and is the lethal form of OI. Their skull is soft with multiple palpable bony islands and long bones are crumpled. Type III OI is manifested in the newborn or infant with severe bone fragility and multiple fractures. The sclera is blue at birth but fades with age. Their birth weight and length tend to be normal but are reduced by subsequent fractures and bowing deformities of long bones. Few reach adult life. Type IV OI is rare but more difficult to diagnose. The sclera is normal, family history may not be present, and radiographs can be normal. The diagnosis may not be made until teeth have formed and dentinogenesis imperfecta is seen.45
Other skeletal abnormalities are seen with copper deficiency or Menke’s syndrome, which is an X-linked recessive disorder that involves inadequate copper absorption.46 These children have profound mental and physical retardation, alopecia, osteoporosis of the long bones, rib fractures, wormian bones, and metaphyseal fractures similar to those seen in child abuse.47,48
Rickets and scurvy also produce radiologic bone abnormalities resembling child abuse. Rickets results in cupping and fraying of the metaphysis and increased distance between the metaphysis secondary to deposition of uncalcified bone as well as demineralization and thinning of the cortex and epiphysis.49,50 With scurvy, the epiphysis is outlined by an increased density of the zone of provisional calcification where fractures traverse into the metaphysis. With healing, the elevated periosteum may become calcified giving a radiologic finding similar to fractures seen in child abuse.48 Congenital syphilis, congenital insensitivity to pain and certain drugs including vitamin A, methotrexate, and prostaglandins also may have bony abnormalities associated with them that may be suggestive of child abuse.51,52
The misdiagnosis of child abuse is also made with several diseases that manifest their presence with cutaneous lesions mistaken for bruising. Mongolian spots are grayish-blue, are present from birth in dark-skinned- children, are located usually over the buttocks and/or lower back, and are non-tender. Coagulopathies such as hemophilia and Von Willebrand disease, ingestion of anticoagulants (salicylates, rat poison), leukemia, and neuroblastoma may produce purpura suggesting abuse.53,54
Folk Remedies or Child Abuse?
Many folk remedies have been mistaken for child abuse. "Cupping" is practiced by Mexican and Eastern European immigrants to restore appetite, relieve vertigo, and reduce inflammation. Alcohol is placed in a cup and ignited then placed on the skin creating a vacuum which results in a circular echymotic ring.55 Cao Gio ("coining") and Quat Sha ("spooning"), practiced by Southeast Asians for fever and headache, is performed by rubbing a coin or spoon heated in hot oil on an ill child’s neck, spine, and ribs until echymotic lesions appear.56,57,58 Caida de Mollera or sunken fontanelle is believed by Hispanics to be the cause of vomiting, diarrhea, and lethargy. An attempt is made to elevate the fontanelle by holding the child upside down and vigorously shaking, thus resulting in retinal hemorrhages53,59 Moxibustion and Maquas are two additional forms of folk medicine where induced burns are believed to draw out illnesses.60
Reporting Suspected Child Abuse
Every state has a statute for discovering and reporting child abuse with the reporter being immune from both civil and criminal liability, but penalized if he or she does not report.61 Mandated reporters include physicians, dentists, podiatrists, nurses, psychologists, speech pathologists, coroners, medical examiners, child day care center employees, childrens’ service workers, social workers, and school teachers.15 Reportable conditions include non accidental physical injury, neglect, sexual abuse, and emotional abuse. However, each state defines them differently.15 For child protective service agencies, the primary purpose is to protect and ensure the safety of children who have been or are at risk of maltreatment, and to provide services to alter the conditions that create risk of maltreatment in the future.62 Child abuse reporting statutes dictate when a report must be made. Most statutes require reporters to make an immediate oral report by telephone to one of four traditional agencies: social service agencies, police department, health department, or juvenile court.15
Documentation is critical, and the interview and physical examination should be performed by the most experienced individual. The aid of social workers should not be delayed. After the work-up and reporting has been completed, and if it is believed the that the child is not safe, he or she should be hospitalized pending further evaluation.
Summary
While accidents happen, the incidence of child maltreatment has reached epidemic proportions. In order to distinguish between intentional and unintentional injury, the physician needs to be familiar with the common unintentional pediatric fractures and their mechanism of injury as well as fractures that are commonly abusive. (See Table 2.) They must also have an understanding of the normal developmental stages of childhood. While there are fractures that are classic for the diagnosis of child abuse, most fractures that are abusive are not in this category. Almost any type of fracture can occur in the abused child and it is imperative to perform a thorough history and physical on every injured patient to help determine the origin of each injury. It is the responsibility of all clinicians to become familiar with the signs of child abuse and consider every pediatric fracture as a possible fracture of abuse.
Acknowledgments
We would like to thank Dr. Alex Imas for his excellent illustrations. We would also like to thank Anne Marie Wronikowski and Kim Mahoney for their secretarial assistance in typing this paper.
References
1. Reece DM. Child Abuse: Medical Diagnosis and Management. Philadelphia: Lea and Febiger; 1994:23-50.
2. King J, Diefendorf D, Apthorp J, et al. Analysis of 429 fractures in 189 battered children. J Ped Ortho 1988;8:585-589.
3. Leventhal JM, et al. Fractures in young childrendistinguishing child abuse from unintentional injuries. Am J Dis Children 1993;147:87-92.
4. Thomas SA, Rosenfield NS, Levanathal JM, et al. Long-bone fractures in young children: Distinguishing accidental injuries form child abuse. Pediatrics 1991;88:471-476.
5. Johnson CF. Inflicted injury vs. accidental injury. Peds Clin North Am 1990;37:791-811.
6. Cappelleri JC, Eckenrode J. The epidemiology of child abuse: Findings from the second national incidence and prevalence study of child abuse and neglect. Am J Public Health 1993;83:1622-1624.
7. Newberger E. Child physical abuse. Ped Clin North Am 1993;20:317-327.
8. McClain PW, Sacks JJ, et al. Estimates of fatal child abuse and neglect, United States, 1979 through 1988. Pediatrics 1993;91:338-343.
9. Rockwood CA, Wilkins KC, King RE. Fractures in Children. 3rd ed. Philadelphia, PA: Lippincott Co; 1991:1-6.
10. Rang, Mercer. Children’s Fractures. 2nd ed. Philadelphia, PA: Lippincott Co; 1983:1-15.
11. England SP, Sundberg S. Management of common pediatric fractures. Ped Clin North Am 1996;43:991-1013.
12. Swischuk LE. Emergency Imaging of Acutely Ill or Injured Child. 3rd ed. Baltimore: Williams and Wilkins; 1994:361-363.
13. Merten DF, Carpenter BC. Radiologic imaging of inflicted injury in the child abuse syndrome. Ped Clin North Am 1990;37:815-837.
14. Kleinman PK, Nimkin K, et al. Follow-up skeletal surveys in suspected child abuse. Am J Radiology 1996;167:893-896.
15. Broduer AE, Monteleone JA. Child Maltreatment. A Clinical Guide and Reference. St. Louis: GW Medial Publishing, Inc; 1994:32.
16. Pergolizzi R, Oestrich AE. Child abuse fracture through physiologic reaction. Pediatr Radiol 1995;25:566-567.
17. Kleinmen PK, Marks SC, Richmond JM, et al. Inflicted skeletal injury: A postmortem-radiologic-histopathologic study in 31 infants. Am J Radiol 1995;165:647-650.
18. Silverman FN, Kuhn JP, eds. Caffey’s Pediatric X-Ray Diagnosis: An Integrated Imaging Approach. St. Louis: The CV Mosby Co.; 1992:1814-1816.
19. Kleinman PK, Marks SC, Blackbourne B. The metaphyseal lesion in abused infants: A radiographic histologic study. Am J Radiol 1986;146:895-905.
20. Strait RT, Siegel RM, Shapiro RA. Humeral fractures without obvious etiologies in children less than 3 years of age: When is it abuse? Pediatrics 1995;96:667-671.
21. Merten DF, Radkowski MA, Leonidar JC. The abused child: A radiologic reappraisal. Radiology 1983;146:377-381.
22. Worlock P, Stower M, Barbor P. Patterns of fractures in accidental and nonaccidental injury in children: A comparative study. BMJ 1986;293:100-102.
23. Kleinman PK, Marks SC. A regional approach to the classic metaphyseal lesion in abused infants: The proximal tibia. Am J Radiol 1996;166:421-426.
24. Hobbs CJ. Skull fracture and the diagnosis of abuse. Arch Dis Child 1984;59:246-252.
25. Kowal-Vern A, Paxton TP, Ross SP, et al. Fractures in the under 3-year-old cohort. Clin Pediatr 1992;31:653-659.
26. Rosenberg N, Bettenfield G. Fractures in infants: A sign of child abuse. Ann Emerg Med 1982;11:178-218.
27. Kleinman PK, Marks SC. A regional approach to the classic metaphyseal lesion in abused infants: The proximal humerus. Am J Radiol 1996;167:1399-1403.
28. Meservy CJ, Towbin R, McLaurin RL, et al. Radiographic characteristics of skull fractures resulting from child abuse. Am J Radiol 1987;149:173-174.
29. Reisdorff EJ, Roberts MR Wiegenstein JG, eds. Pediatric Emergency Medicine. Philedelphia: W.B. Saunders Co.;1993.
30. O’Neill JA. Patterns of injury in the battered child syndrome. J Trauma 1973;13:332-339.
31. Kleinman PK, Marks SC, Mimkin K, et al. Rib fractures in 31 abused infants: Postmortem radiologic-histopathologic study. Radiology 1996;200:807-810.
32. Strouse PJ, Owings CL. Fractures of the first rib in child abuse. Radiology 1995;197:763-765.
33. Feldman KW, Brewer DK. Child abuse, cardiopulmonary resuscitation, and rib fractures. Pediatrics 1984;73:339.
34. Kleinman PK. Diagnostic Imaging of Child Abuse. Baltimore: Williams and Wilkins; 1987.
35. Helfer RE, Slouis TL, Black M. Injuries resulting when small children fall out of bed. Pediatrics 1977;60:533.
36. Anderson WA. The significance of femoral fractures in children. Ann Emerg Med 1982;11:174-177.
37. Dickson RA, Leatherman KD. Spinal injuries in child abuse: Case report. J Trauma 1978;18:811-812.
38. Kleinman PK, Zito JL. Avulsion of the spinous processes caused by infant abuse. Radiology 1984;151:389-937.
39. McGrory BE, Fenichel GM. Hangmans fracture subsequent to shaking an infant. Ann Neurol 1977;2:82.
40. Kogutt MS, Swishuck LE, Feagan CJ. Pattern of injury and significance of uncommon fractures in the battered child syndrome. Am J Radiol 1974;121:143.
41. Cummings WA. Neonatal skeletal fractures: Birth trauma or child abuse. J Can Assoc Radiol 1979;30:30-33.
42. Gahagan S, Rimsza ME. Child abuse or osteogenesis imperfecta: How can we tell? Pediatrics 1191;88:987-992.
43. Ojima K, Matsumoto H, Hayase T, et al. An autopsy case of osteogenesis imperfecta initially suspected as child abuse. Forensic Sci Int 1994;65:97-104.
44. Wright JT, Thornton JB. Osteogenesis imperfecta with dentinogenesis imperfecta: A mistaken case of child abuse. Pediatric Dentistry 1983;5:207-209.
45. Augarten A, Laufer J, et al. Child abuse, osteogenesis imperfecta and the grey zone between them. J Med 1993;24:171-175.
46. Danks DM, et al. Menke’s kinky hair syndrome. Pediatrics 1972;50:188-201.
47. Martin LA, McNemar A, O’Brien E. Menke’s kinky hair disease. MCN 1994;19162-164.
48. Brill PW, Winchester P. Differential diagnosis of child abuse. In: Kleinman PK, ed. Diagnostic Imaging of Child Abuse. Baltimore: Williams & Wilkins; 1987:221-241.
49. Kaplan S. Clinical Pediatric Endocrinology. Philadelphia: Saunders; 1990:442-443.
50. Zeiss J, Wycliffe ND. Radiological case of the month. Am J Dis Child 1988;142:1367-1368.
51. Stewart GM, Rosenberg NM. Conditions mistaken for child abuse. Pediatr Emerg Care 1996;12:116-121.
52. Lim HK, Smith WL, et al. Congenital syphilis mimicking child abuse. Pediatr Radiol 1995;25:560-561.
53. Bays J. Conditions mistaken for child abuse. In: Reece R., ed. Child Abuse: Medical Diagnosis and Management. Philadelphia: Lea & Febiger; 1994:358-385.
54. Haddad LM, Winchester Jf, eds. Clinical Management of Poisoning and Drug Overdose. Philadelphia: WB Saunders; 1990;914-915.
55. Sandler AP, Haynes V. Nonaccidental trauma and medical folk belief: A case report of cupping. Pediatrics 1978;61921-922.
56. Yeatman FW, Shaw C, Barlow Mj, et al. Pseudo-battering in Vietnamese children. Pediatrics 1976;58:616-618.
57. Leung AKC. Ecchymosis from spoon scratching simulating child abuse. Clin Pediatr 1986;25:98.
58. Gellis S, Feingold M. Cao Gio: Pseudobattering in Vietnamese Children. Am J Dis Child 1976;130:857-858.
59. Guarnaschelli J, Lee J, Pitts FW. Fallen fontanelle (Caida de Mollera): A variant of the battered child syndrome. JAMA 1972;222:1545.
60. Stewart GM, Rosenberg NM. Conditions mistaken for child abuse. Pediatr Emerg Care 1996;12:116-121.
61. Landers J. Flood: 17 California, 3d 399, 551, p. 2d; 389, 131 Cal Rpt. 1976; 69.
62. Cunningham C, Horowitz R. Child abuse and Neglect: Cases, Text, and Problems. American Bar Association, National Legal Resource Center for Child Advocacy and Protection, Washington, DC 1989.
Physician CME Questions
Correction: In the December 1997 issue of Pediatric Emergency Medicine Reports, the questions were incorrectly numbered. The correct numbers should read 30-37. Please answer these questions on the answer sheet in the spaces provided for question 30-37. We apologize for any inconvenience.
1. Which of the following statements is true about the bones of a child?
A. Periosteal reaction on x-ray indicates that a fracture has occurred.
B. Perfect realignment is needed to ensure adequate growth in all fractures of childhood.
C. Children are more likely to sustain a fracture than a sprain.
D. Salter-Harris type I fractures have the worst prognosis for subsequent growth.
2. Which of the following statements is true about radiographic evolution of child abuse?
A. Skeletal survey is rarely indicated in a child older than 5 years.
B. A normal skeletal survey will rule out child abuse.
C. Bone scan should be performed on all children with suspected abuse.
D. It is very unusual to find additional fractures in a skeletal survey when abuse is strongly suspected.
3. Which of the following histories is most consistent with a non-accidental injury?
A. A 3-year-old child sustains an oblique fracture to the tibia after running and tripping.
B. A 6-month-old child fell out of his father’s arms and sustained a linear parietal skull fracture. A CT scan of the head was otherwise normal.
C. A 2-year-old child fell off a slide and has a supracondylar fracture of the elbow.
D. A 1-year-old child sustained a midshaft clavicular fracture after falling down three steps in a walker.
E. A 2-month-old infant rolled out of bed and has a midshaft femur fracture.
4. Which of these fractures is diagnostic of child abuse?
A. Oblique fractures of the distal tibia in a 2 year old
B. A bucket handle fracture of the distal humerus
C. Salter-Harris II fracture of the radius
D. Torus fracture of the distal radius
5. A 1-year-old girl has history of not moving her arm for one day. The family denies any history of trauma. An x-ray reveals a midshaft humeral fracture. The next step in the work up of this child wold be:
A. order a CT scan of the head to rule out a chronic subdural hematoma.
B. order liver enzymes to help rule out intra-abdominal injury.
C. obtain a skeletal survey to rule out other fractures.
D. apply a sling and swath and have the patient follow up with orthopedics
6. Which of the following fractures is likely to be unintentional?
A. Posterior rib fracture
B. Metaphyseal lucency
C. Avulsion fracture of the lateral tip of the clavical
D. Supracondylar fracture of the humerus
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