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“FRACTURES: WHEN TO
CONSIDER ABUSE”
ARNE GRAFF MD
MAYO CLINIC-ROCHESTER
OBJECTIVES:
• RECOGNIZE RISK FACTORS ASSOCIATED WITH
ABUSE
• DEVELOP EVALUATION PROCESS
• HOW TO DEVELOP AN IMPRESSION
DISCLOSURE:
• NONE
• DO PARTICIPATE IN COURT CASES FOR BOTH
THE DEFENSE AND PROSECUTORS
CASE
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6 MONTH OLD MALE INFANT
PRESENTS WITH MULTIPLE BRUISES
NO HISTORY
SKELETAL SURVEY SHOWS DIAPHYSEAL
TRANSVERSE FEMUR FRACTURE; NO OTHER
INJURIES
PA IN CHILDREN
• #1 BRUISES
• #2 FRACTURES
TYPICAL CASE:
• THERE ISN’T ONE
• EACH CASE MUST BE EVALUATED ON THE
COMPLETE HISTORY AND WORKUP
OUR ROLE:
• TO PROVE IT’S NOT ABUSE
• CONSIDER:
– INJURY = HISTORY = ABILITY = MECHANICS
• DIFFERENTIAL DIAGNOSIS:
– MEDICAL
– ACCIDENTAL: WITNESSED OR UNWITNESSED
– NONACCIDENTAL
FAILURE TO RECOGNIZE:
MORE SERIOUS HARM TO
CHILD!
THINGS TO CONSIDER:
• CONSIDER ALL FORMS OF ABUSE COEXISTING
• CONSIDER WHOLE PICTURE:
– CONSISTENT HISTORY?
– TIMELY CARE SOUGHT?
– SIGNS AND SYMPTOMS CONSISTENT?
STARTING POINT:
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HISTORY
AGE OF CHILD
DEVELOPMENT OF CHILD
TYPE OF FRACTURE
LOCATION OF FRACTURE
“AGE” OF FRACTURE
MECHANICS OF INJURY
WHO DID IT ?
IN FACT IT IS NOT YOUR JOB
OR MINE TO DETERMINE WHO
DID IT!
OUR JOB IS TO BE MEDICAL
EXPERTS AND EXPLAIN
POTENTIAL CAUSE.
KEY HISTORY:
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FMH: FRACTURES, HEARING, DENTAL, GENETICS
MEDICATIONS
SOCIAL HISTORY: DV, non-BIOLOGICAL CAREGIVER
PMH: MEDICAL CONDITIONS (renal, etc), PREMIE
NUTRITIONAL: diet, VLGW
SOCIAL SERVICE Hx: abuse, IPV, neglect, other
TYPICAL HISTORY:
• NONE
• VAGUE
• MINOR INJURY; INCONSISTENT WITH INJURY
• HOWEVER, EVEN MINOR FALL CAN FX!
ABUSIVE FRACTURES:
• 20-30% OF PA VICTIMS
• MOST OFTEN IN INFANT/TODDLER
• 80% OF ABUSIVE FX <18 MOS AGE
• 25% OF FX <1YR OLD ARE ABUSIVE
HOWEVER, OVERALL
ABUSIVE FRACTURS ARE A
SMALL PERCENT OF TOTAL
PEDS FRACTURES!
85% OF NON-ABUSE FRACTURES ARE
OVER THE AGE OF 5
CONCERNING FRACTURES:
• MULTIPLE FRACTURES
• MULTIPLE STAGES OF HEALING
• PRESENCE OF SUBPERIOLSTEAL NEW BONE
FORMATION (<1 M OR >6 M)
KEY POINTS:
• PRESENCE OF A FRACTURE DOES NOT PROVE
ABUSE
• NO FRACTURE IS PATHOPNEUMONIC OF
ABUSE
RED FLAGS:
• DEVELOPMENT OF CHILD
• DELAY IN SEEKING CARE
• NON-MOBILE CHILD (INFANT)
• ANY INFANT FRACTURE WITHOUT HISTORY
• LACK OF EXTERNAL SIGNS
DOES NOT RULE OUT
INJURY!
HISTORY:
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INJURY HISTORY
PAST MEDICAL HISTORY
DEVELOPMENT HISTORY
FAMILY MEDICAL HISTORY
MEDICATIONS
SOCIAL HISTORY
KEY CONSIDERATIONS:
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INJURY = HISTORY
CONSISTENT HISTORY (ER, EMS, YOURS)
DEVELOPMENTAL HISTORY FIT
CHILD’S RESPONSE TO INJURY FIT
INJURY TO CARE TIME
OTHER INJURIES
SOCIAL RISKS
ACCIDENTS OCCUR;
CAREGIVERS ARE
EMBARRESSED!
HISTORY CHALLENGES:
• PROVIDER RELIES ON CAREGIVER HISTORY
• OFTEN “NO” HISTORY
• PATIENT OFTEN UNABLE TO GIVE HISTORY
• LIMITED STUDIES FOR SORTING OUT
SYMPTOMS:
• LIMITED MOVEMENT OF EXTREMITY
• CRYING OR PAIN WITH MOVEMENT
• MAY NOT SEE RESPIRATORY CHANGE
• OR……..CRYING AND NOT CONSOLABLE
SIGNS:
• NO BRUISING (8-9%)
• NO SWELLING
• NO DEFORMITY
• LIMITED TENDERNESS, IF ANY
HEAD TO TOES EXAM:
• INJURIES
• NEUROLOGICAL EXAM
• DEVELOPMENTAL EXAM
• OTHER FINDINGS (CONNECTIVE TISSUE, ETC)
RADIOLOGY EVAL
SKELETAL SURVEY
• AGE INDICATIONS FOR ABUSE:
<2: FULL SKELETAL SURVEY
2-5: CASE BY CASE (AGE 2-3)
>5: INDIVIDUAL FILMS OF INJURIES
SKELETAL SURVEY:
• NOT A “BABYGRAM”
• INCLUDES:
AP VIEWS OF ARMS, FORARMS, HANDS,
FEMURS, LOWER LEGS*, FEET
PA OF CHEST WITH OBLIQUES*
LATERAL OF COMPLETE SPINE
AP AND LATERAL OF SKULL
AP OF PELVIS
LIMITED RADIATION
EXPOSURE
SKELETAL SURVEYS:
• FIRST SKELETAL SURVEY NEGATIVE; VALUE?
• REPEAT SS IN TWO WEEKS
– WHAT TO REPEAT; WHAT TO OMIT?
SKELETAL SURVEY
RADIOLOGY:
BONE SCANS:
SENSITIVE TEST:
NEW RIB FRACTURES (7-10 DAY)
SUBTLE DIAPHYSEAL FRACTURES
EARLY PERIOSTEAL ELEVATIONS
MOST FRACTURES BY 48 HOURS
LESS SENSITIVE:
SKULL FRACTURES
DATING FRACTURES
NBPF
• NEW PERIOSTEAL BONE FORMATION
• NOT PHYSIOLOGIC:
> 2mm
EXTENDS TO METAPHYSIS
NOT LAMINAR
1MONTH < PATIENT AGE > 4 MONTHS
GROWTH ARREST LINES
• NOT SPECIFIC FOR MALTREATMENT
• SLOW GROWTH TIMES
• RELATED TO PHYSIOLOGIC STRESS AS WITH
ILLNESS OR STARVATION
• BREAK DOWN WITH TIME
Figure 4.2
Reproduced with permission from Moseley CF, (ed): Your Orthopaedic Connection.
Rosemont, IL, American Academy of Orthapaedic Surgeons.
“GROUND UP STRENGTH”
FRACTURE MECHANICS:
• TRANSVERSE: BENDING LOAD PERPENDICULAR
• SPIRAL: TORSION OR TWIST TO LONG AXIS
• OBLIQUE: TORSION AND BEND COMBO
• BUCKLE: COMPRESSION ALONG LONG AXIS
MORE FX MECHANICS:
• SHORT FALL ONTO KNEE: torus or impacted
transverse distal femur fx
• STAIRWAY FALL: twisted lower leg resulting in
spiral femur fracture
No Caption Found
OBLIQUE DISTAL FEMUR FX
Grant, P. et al. Pediatrics 2001;108:1009-1011
Copyright ©2001 American Academy of Pediatrics
“SERIES OF
FALLS”
AGE/DEVELOPMENT:
• TYPES AND CAUSES VARY FOR DIFFERENT
STAGES OF AGE/DEVELOPMENT
– FEMUR
• TODDLER, SPORTS
• ? PULL TO STAND
– UPPER EXTREMITY
• SUPRACONDYLAR, DISTAL FORARM, SWOOSH
MECHANICS AND AGE:
• HUMERAL DIAPHYSEAL FRACTURE
– <18 MOS; HIGH RISK FOR ABUSE
• SUPRACONDYLAR FRACTURE
– ABULATORY CHILD; LOW RISK
Kids heal fast!!
FRACTURES “SPECIFICITY”
• FEMUR: TRANSVERS AND SPIRAL; BOTH
• RIBS: >1 FX SUGGESTIVE OF ABUSE
– UNILATERAL OR BILATERAL
– WITHOUT HX; HIGH SPECIFICITY
• SKULL: <3 MOST COMMON; BOTH
– PARIETAL
– LINEAR
– COMPLEX FX ???
MUTI-AGED
FRACTURES
rib
ACCIDENTAL AND ABUSE
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FEMUR (toddler fracture)
TIBIA/FIBULA (toddler fracture)
HUMERUS (under 12mos 43% abuse)
RADIUS/ULNA (>5)
SKULL: most common fracture < 2yr
CLAVICLE (most common peds fracture)
CML POINTS:
• CMLS’S: HIGHLY PREDICTIVE IN CHILD <1Y/O
• CML: MOST COMMON FRACTURE IN FATAL CASES
• CORNER OR BUCKET-HANDLE NAME
• PLANAR FX THROUGH PRIMARY SPONGEOSIUM
• MECHANICS: TWIST, PULL, SHAKE
CMLS
OTHER FRACTURES:
• CLAVICLE: COMMON PEDS INJURY
BIRTH TRAUMA (10-14DAY)
USUALLY MIDSHAFT
AC FX—VIOLENT TRACTION
VERTEBRAL: RARE; MRI STUDY
HYPERFLEXION OF TORSO
AND AXIAL SPINE LOADING
VERTEBRAL INJURIES:
HYPEREXTENSION
HYPERFLEXION
COMPRESSION
Table 3 Specificity of fracture locations [77].
• Specificity Fracture
• High Classic metaphyseal lesions
• Rib fractures (especially posteromedial)
• Scapular fractures
• Spinous process fractures
• Sternal fractures
HIGH
SPECIFICITY
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Moderate Multiple fractures (especially bilateral)
Fractures of different ages
Epiphyseal separations
MODERATE
Vertebral body fractures and subluxations
SPECIFICITY
Digital fractures
Complex skull fractures
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Low Subperiosteal new bone formation
Clavicular fractures
Long-bone shaft fractures
Linear skull fractures
LOW SPECIFICITY
HARD
TO
DATE!
HEALING VARIES:
• BY SITE
• TYPE OF INJURY
• CARE/REINJURY
HEALING FACTORS:
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IMMOBILIZATION
REPEATED TRAUMA
DISEASE
AGE
SEVERITY OF INJRUY
DEGREE OF DISPLACEMENT
HEALING FRACTURES
• IMPORTANT TO NOTE NORMAL HEALING FOR
FRACTURES
• NOTE LACK OF NEW FRACTURES WHILE IN
FOSTER/KINSHIP CARE
NORMAL VARIENTS
OTHER RADIOLOGY
AIDS
3-D CT
STIR
STUDIES
FRACTURE LABS
INITIAL LABS:
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Ca
Phosphorus
Vit D
PTH
ALK PHOS
PA’S OTHER LABS:
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AMYLASE
LIPASE
UA
SGOT, SGPT
MEDICAL FX CAUSES:
• OI
• OTEOPENIA OF PREMATURIT
– OSTEOPENIA BY 6-12 WEEKS OLD
– RESOLVES BY 1 YR (IF OTHERWISE DOING WELL)
• “TEMPORARY BRITTLE BONE DISEASE”
– NOT A CLINICAL ENTITY
MEDICAL FX CAUSES:
• COPPER DEF
– PRETERM INFANT
– PATHOLOGIC FRACTURES
– OTHER: sideroblastic anemia, neutropenia
– CHECK: ceruloplasmin, copper
• VIT D DEFICIENCY
• EDS
• OTHER: menke’s, renal, paralysis, etc
GENETICS CONSULT?
ENDOCRINE (BONE)
CONSULT?
CASE #1
• 9 MOS INFANT
• URI
• RIB FRACTURE NOTED
• OTHERWISE NEG SK S AND REPEAT NEG
• ? ACCIDENTAL; ISOLATED FRACTURE
CASE #2
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3 YR OLD JUMPING OFF BED
DAD REPORTS SHE LANDS AND CRIES OUT
WON’T BEAR WEIGHT
PAST HISTORY NEG
SINGLE DAD; NO CPS HISTORY
CASE #2
• NEG SKEL SURVEY
• PATIENT’S HISTORY
YOUR HOSPITAL:
• PROTOCOL ? FOR ABUSE/FX
• ARTICLES/WORK WITH RADS
SUMMARY POINTS:
• ACCIDENTS CAN FX ANY BONE
• CONSIDER:
– INJURY = HISTORY = ABILITY = MECHANICS
• CONSIDER ALL CAUSES FOR FRACTURE (S)