It isn't always easy to tell when an injury is accidental or the result of child abuse. Emergency room physicians, paediatricians, general practitioners and orthopaedic surgeons are often in the first line in the discovery of an abused child. “To be able to distinguish 'normal' physical injuries from neglect or abuse, the physician needs to first of all have a high level of suspicion in all injuries involving young children, especially if the caretaker gives no clear explanation,”says the Journal of Orthopaedics in a 2009 article entitled “Hospitalized Cases of Child Abuse in America. Who, What, When, and Where.”
Clinical Findings
The orthopaedic surgeon will be confronted by the bony lesions, but will have to look for other “clues” if an abused child is suspected. Although some fracture type or pattern are more often seen in child abuse, there is not one “absolute” sign of abuse; it will have to be added to the other clinical and general findings.
Fractures are the second most common manifestation of abuse, and between 30% and 50% of victims will require the services of an orthopaedic surgeon. Fractures secondary to abuse generally have a good outcome and long-term prognosis. Appropriate referrals and intervention can decrease risk of future abuse (Journal of Orthopaedics).
Common fractures in children include:
- Clavicular fractures
- Long bone shaft fractures
- Linear skull fractures
Highly suspicious fractures include:
- Metaphyseal fractures
- Posterior rib fractures
- Scapular fractures
- Spinous process fractures
- Sternal fractures
Fracture Patterns- Radiological Findings
Multiple age fractures and an unclear history will raise suspicion. Bone scintigraphy as well as X-rays of the entire skeleton need to be done to look for fractures (healed or not). These tests will be very helpful in the young child unable to express himself.
One has to suspect abuse in lower extremity fractures in non-weight-bearing children, in the association of posterior ribs fractures with long bone fractures, in the metaphyseal “corner fracture.”
All other combinations are possible. Some fractures are more specific: for example a metaphyseal corner fracture is caused by pulling forcefully on an extremity. They need good quality X-rays to be seen.
Patients' Age
In a 2009 study conducted by the Children’s Hospital of Philadelphia entitled “Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center,” victims of child abuse were on average younger than accidental trauma patients in the cohort of patients under 48 months of age.
When the entire cohort of patients under 48 months were examined after adjusting for age and sex, the odds of rib (14.4 times), tibia/fibula (6.3 times), radius/ulna (5.8 times), and clavicle fractures (4.4 times) were significantly higher in child abuse versus accidental trauma patients.
When regrouping the data based on age, in patients younger than 18 months of age, the odds of rib (23.7 times), tibia/fibula (12.8 times), humerus (2.3 times), and femur fractures (1.8 times) were found to be significantly higher in the child abuse group. Yet, in the more than 18 months age group, the risk of humerus (3.4 times) and femur fractures (3.3 times) was actually higher in the accidental trauma group than in the child abuse group.
The role of the physician and orthopaedic surgeon is to think of the possibility of child abuse in specific clinical conditions and to alert the appropriate authorities. The management of child abuse involves the diagnosis, the medical treatment and the appropriate social and legal measures.
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