Skeletal Injury

Historically, skeletal injury played a major role in the recognition of child abuse (25,26). In 1946, Caffey (27) described six patients presenting with chronic subdural hematoma in which 23 unexplained fractures of the long bones were found. Caffey concluded that the fractures were traumatic in origin and introduced the concept of inflicted injury.

Most skeletal injuries of NAI occur in children under the age of 2 years, and some may be occult, particularly in the infant younger than 1 yr who has other signs of physical injury. Merten et al. (28) found fractures in 47% of abused children under the age of 1 year who had skeletal surveys, in which 67% were occult and 60% were multiple. Fractures in infants and children resulting from falls of under 3 ft are relatively uncommon. Research evidence suggests that 1% of children falling less than 3 ft may sustain a simple linear skull fracture (29).

Accidental fractures in infants and toddlers do occur, usually as a result of falls, often from a height, but they can occasionally occur in long bones of ambulant children from twisting, running, and falling. There is usually a consistent history and a prompt presentation. Fractures cause pain and distress and are often accompanied by nonuse of the affected body part and local swelling.

Any fracture can occur as a result of NAI, but some have a high specificity for abuse, such as:

• Metaphyseal—a shaking, pulling, or twisting force applied at or about a joint, resulting in a fracture through the growing part of the bone.

• Epiphyseal separation—resulting from torsion of a limb, particularly in children younger than 2 years old.

• Rib—resulting from severe squeezing or direct trauma; posterior rib fractures virtually pathognomonic of NAI and commonly associated with shaking injury.

• Scapular—resulting from direct impact.

• Lateral clavicle—resulting from excessive traction or shaking of an arm.

• Humerus or femur—in nonambulant children (under 1 year); transverse fractures from angulation, including a direct blow; spiral fractures from axial twists with or without axial loading; oblique fractures from angulation, axial twisting with axial loading.

• Vertebral—resulting from hyperflexion injuries, impact injuries, or direct trauma.

• Digital—resulting from forced hyperextension or direct blows.

• Skull—resulting from blunt-impact injuries, particularly occipital fractures and fractures that are depressed, wide (or growing), bilateral, complex, crossing suture lines multiply, or associated with intracranial injury (30).

• Periosteal injury—resulting from pulling or twisting of a limb separating the periosteum from the surface of the bone, leading to hemorrhage between the periosteum and the bone and subsequent calcification.

Other features of skeletal injury suggestive of abuse include the following:

• Absence of an appropriate history.

• Multiple fractures.

• Fractures of differing ages.

• Fracture in association with other features of NAI (e.g., bruising at other sites).

• Unsuspected fractures (recent or old) found when X-rays taken for other reasons.

Precise dating of fractures cannot be achieved, although ranges of fracture ages are available. Advice from an experienced pediatric radiologist should be sought to assist with dating injuries, to obtain further radiological or other imaging views, and to exclude other causes of skeletal abnormality.

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