Medical assessment of fractures in suspected child maltreatment: infants and young children

Question 1

What fracture type is pathognomonic for inflicted injury?

Answer 1

No specific fracture type is pathognomonic for inflicted injury

Question 2

What are red flags for inflicted fractures?

Answer 2

Historical

• no hx of trauma/unwitnessed injury
• delay in seeking medical attention
• hx changes with repitition
• hx incompatible with age/developmental stage OR with injury

Clinical

• age < 1 yr
• high risk fractures:
  
  • rib #
  • humerus # < 18 mo
  • femur # in non-ambulatory child
  • metaphyseal #
• multiple #
• # different ages
• presence of other injuries

Question 3

How to differentiate inflicted from accidental fractures?

Answer 3

1. Age of child
   * Accidental fractures uncommon in children <18 months
2. Pattern of skeletal injury
   * Association between multiple fractures and physical abuse
   * rib fracture
   * humerus <18 mo
   * femur # in non-ambulatory (but could be from fall in arms of caregiver)
   * metaphyseal
   * scapular, spinous process, sternal
3. Presence of other injuries - bruising, oral, intracranial/abdo
4. Medical conditions predisposing to skeletal injury
   - child abuse more common than bone disorders

Question 4

What is the differential for fractures?

Answer 4

1. Trauma
   - birth, accidental, inflicted
2. Genetic bone disorder
   - OI, menkes, infantile cortical hyperostosis, hypophosphatasia
3. Nutritional/metabolic
   - vit D deficiency rickets, osteopenia of prematurity, copper def, chronic renal insufficiency, scurvy
4. Infection
   - osteo, congenital syphilis
5. Toxicity
   - hypervitaminosis A, methotrexate toxicity
6. Neoplastic disorder
   - leukemia, LCH

Question 5

Whats the lab evaluation for fractures in suspected child maltreatment?

Answer 5

• CBC
• Renal and liver function
• Ca, Phos, ALP
• UA
• When indicated: PTH, 25-OH vitamin D, serum copper, ceruloplasmin

Question 6

What kind of imaging do you do in suspected child maltreatment?

Answer 6

Skeletal survey

• any child < 2 years of age when there is concern for physical maltreatment
• Consider 2-5 years when there is a strong likelihood of occult inflicted injury
• Follow up:
  
  • If initial SS is negative or equivocal and maltreatment remains a concern, a follow-up should be done approx 2 weeks later

Bone scan may be helpful when used in conjunction with skeletal survey but shouldn’t be used for diagnosis
* However: poor sensitivity for metaphyseal, epiphyseal and skull fractures

Question 7

What does bone scan have poor sensitivity for in fractures?

Answer 7

metaphyseal, epiphyseal and skull fractures

Question 8

What findings on imaging can be used for dating skeletal injuries?

Answer 8

soft-tissue swelling, periosteal reaction, callus formation, remodelling

Question 9

Which parts of the skeletal survey can be omitted in the 2 week follow up?

Answer 9

Consider omitting skull, pelvis and lateral spine in follow-up studies

(typically identified on initial series and eliminating them later reduces radiation exposure)

Question 10

What exam should be done in all children with head injury in context of suspected child maltreatment?

Answer 10

Ophtho consult!