Medical assessment of fractures in suspected child maltreatment: Infants and young children with skeletal injury - CPS Statement

Question 1

A second skeletal survey can be repeated in what time frame to assess for evolving injuries

Answer 1

10 - 14 days after the initial scan

Question 2

What are 4 historical red flags for inflicted trauma in a child with fracture?

Answer 2

No history of trauma/unwitnessed injury

History incompable with age/developmental stage OR with injury

History changes with repetition

Delay in seeking medical attention

Question 3

As per the CPS - what are considered high risk fractures?

Answer 3

Rib fractures

Metaphyseal fractures

Humerus fracture < 18 months

Femur fracture in a non-ambulatory child

Question 4

Accidental fractures are considered uncommon in children less than ____ months of age.

Answer 4

18 months

Question 5

Children under ____ months of age rarely sustain humeral fractures.

Answer 5

18 months

Question 6

What type of femur fractures can occur in ambulatory children who stumble or fall?

Answer 6

Any type including spiral or oblique, transverse or ‘buckle’

Question 7

What three “S” fractures are concerning for inflicted injury?

Answer 7

Scapular
Spinous
Sternal

Question 8

What vitamin and mineral deficiencies are on the differential with a case of skeletal injury?

Answer 8

Vitamin C (scurvy)
Vitamin D deficiency
Copper deficiency

Question 9

Excess of which vitamin is on the differential with a case of skeletal injury?

Answer 9

Hypervitaminosis A

Question 10

Which genetic disorder can present with subdural collections, acute neurologic deterioration, retinal hemorrhage, metaphyseal end plate changes resembling the classic metaphyseal fracture, and other fractures?

Answer 10

Menkes disease - X linked disorder with a defect in copper transport

Question 11

As per the CPS statement, what two infections are on the differential with a presentation of skeletal injury?

Answer 11

1) Osteomyelitis
2) Congenital syphilis

Question 12

What labs do you send in a child presenting with concerning fracture?

Answer 12

Complete blood count

Renal and liver function tests

Serum calcium, phosphate and alkaline phosphatase (also send magnesium)

Urinalysis

When clinically indicated:
Parathyroid hormone
25-hydroxy-vitamin D
Serum copper
Ceruloplasmin

Question 13

What areas of the body may be omitted on repeat skeletal scan? Why?

Answer 13

Consider omitting images of skull, pelvis and lateral spine on follow-up studies, because injuries to this area are typically identified on initial series and this will reduce radiation exposure