Orthopaedic Aspects of Child Abuse NAT Abdulaziz Alomar, MD, MSc FRCSC Assistant Professor and consultant Orthopaedic surgeon. KKUH, KSU Child Abuse
A major cause of disability and death among children. Fractures are the second most common presentation of physical abuse after skin lesions. One third of physically abused children will require orthopaedic treatment. Definition at a minimum, any act or failure to act resulting in imminent risk of
serious harm, death, serious physical or emotional harm, sexual abuse, or exploitation of a child by a parent or caretaker who is responsible for the childs welfare. Type of Maltreatment Neglected (52%) 2. Physical abuse (25%) 3. Sexual abuse (13%) 4. Emotional maltreatment (5%) 5. Medical neglect (3%) 1.
Risk factors
First-born children. Unplanned children. Premature infants. Stepchildren. Handicapped children. Single-parent homes. Drug abusing parents. Parents who were themselves abused. Unemployed parents. Families of lower socioeconomic status. The majority of maltreated children
are abused by birth parents. Who is at Risk? Most children with NAT fractures age of < 3 years Whos at Risk? Most femur fxs in children who are < 1 yo of age are from NAT (60-70%)
Most femur fxs in children > 1yo accidental Clinical Features History: Delay in presenting. History vague, lacking in detail, contradictory Mechanism of injury insufficient to
explain injuries History of a fall Clinical Features History : Less than 3 years old Poor household environment, drug or physical abuse Overly aggressive or passive Behavioral problems
Handicapped child Stepchild Premature child Subnormal growth Non Orthopaedic Features Skin: Bruises (buttocks, perineum and genitalia, trunk,
back of head and legs). Multiple bruises in various stages of healing Burns (pattern may reflect mechanism of burn). Head and CNS:
Skull fracture (multiple, bilateral, skull base, crossing nervous system suture lines, depressed fractures) Subdural hematoma, subarachnoid hemorrhage Retinal hemorrhage, retinal detachment Cognitive disabilities Non Orthopaedic Features
Chest, abdomen, and pelvis: Rib fractures (posterior, multiple), Sternal fractures and pelvis. Pneumothorax, hemothorax Rupture of organ (liver, spleen, or pancreas laceration;bowel or bladder rupture) Intramural bowel hematoma Kidney contusion, retroperitoneal hemorrhage Sexual abuse Orthopaedic Features
Multiple fractures system Fractures in various stages of healing Metaphyseal corner fracture Long-bone fracture in child <2 yr
Vertebral compression fractures, spinous process avulsion. Scapular fracture Epiphyseal separation
Fractures Commonly seen in NAT - High Specificity Femur fracture in child < 1 year old Humeral shaft fracture in < 3 year old Sternal fractures Metaphyseal corner (bucket-handle) fractures
Posterior rib fxs Digit fractures in nonambulatory children 50% to 69% of all fractures occurred in children less than 1year of age. 78% to 85% occurred in children less than 3 years of age.
Timetable for Estimating the Age of Fractures in Children Radiographic Appearance Early Peak Late Resolution of soft-tissue swelling, days 2-5
4-10 10-21 New periosteal bone, days 4-10 10-14 14-21
Loss of definition of fracture line, days 10-14 14-21 21-42 Presence of soft callus, days 10-14 14-21
21-28 Presence of hard callus, days 14-21 21-42 42-90 Remodeling of fracture, months
3 12 24 Radiographic W/U Skeletal survey for children with suspicion of NAT Babygram not sufficient as does not provide necessary detail to identify fractures
Radiographic Work-Up Skeletal survey AP/LAT skull, AP/LAT axial skeleton and trunk, AP bilateral arms, forearms, hands, thighs, legs, feet Repeat skeletal survey at 1-2 weeks can be helpful
2 yo Girl with Proximal and Distal Humerus Fx, L2-L3 Fx-Dislocation Bone Scan Usually reserved for highly suspicious cases with negative skeletal survey Good at picking up rib fxs and vertebral fxs Repeat bone scan at 2 weeks can identify occult injuries
Multiple Vs single # Multiple fractures in various stages of healing are found in more than 70% of abused children less than 1 year of age and more than 50% of all abused children. Krishnan J, Aust N Z J Surg 1990
50% of the children had only a single fracture, 33% had two or three fractures, and 17% had more than three fractures. King et al, J Pediatr Orthop 1988 Most common orthopaedic presentation of children with NAT - 65% of children with fxs Only 13% of children with fractures presented with multiple fractures in different stages of healing Loder, JPO 1991 Patterns of fractures
Spiral Vs transverse 48% to 71% of long-bone fractures in several large series are transverse #. no difference in diaphyseal fracture pattern between fractures due to abuse and those resulting from accidental injury. Beals ,Pediatr Orthop 1983
no difference in diaphyseal fracture pattern between fractures due to abuse and those resulting from accidental injury. Physeal fractures Specific bone Clavicle:
physeal fractures: Most commonly fractured bones in accidental childhood injury. Unusual in child abuse, detected in only 2% to 7% of abused children. Uncommon in the abused child.
Transphyseal fractures of the distal humerus in children less than 1 year old. Spinal :(0% to 3%) Asymptomatic compression fractures detected on skeletal survey. Fracture or avulsion of the spinous processes is fairly specific
to abuse. Hyperflexion and hyperextension associated with violent shaking. Specific bone Femure Most femur fxs in children who are < 1 yo of age are from NAT (60-70%) Most femur fxs in children > 1 yo accidental
Humerus Fxs Diaphyseal fxs in children < 3 yo are very suggestive of NAT!!!!!!! Humerus Fxs Most common fx in some series Supracondylar fxs common in accidental trauma
Transphyseal fxs - high association with NAT Transphyseal Humerus Common in NAT Metaphyseal Vs diaphyseal
Metaphyseal injuries are less common than diaphyseal fractures. Metaphyseal lesions have high specificity and are considered to be a classic radiographic finding in physical abuse Metaphyseal or Bucket Handle Fxs
Mechanism traction and twisting Planar injuries through the primary spongiosum May be picked up at autopsy when not seen on x-ray Corner Fractures Traction/rotation
mechanism of injury Planar fracture through primary spongiosa, creates disklike fragment of bone/cartilage, thicker at periphery Metaphyseal or Bucket Handle Fxs
Pathognomonic of NAT Metaphyseal Bucket Handle Fx Differential Diagnosis
Osteogenesis imperfecta Accidental injury Birth trauma Rickets Coagulation disorders Leukemia Congenital insensitivity to pain
Management - NAT Suspected Professional, tactful, nonjudgmental approach in initial encounter and workup
Explain workup to parents as standard approach to specific ages/injury patterns Early involvement of child protection team if available Early contact/involvement of childs primary care physician Management Documentation
Many cases result in medical records becoming part of legal record Carefully document history, physical exam and radiographic findings Document evidence supporting physical abuse Document statement regarding level of certainty of abuse
