Patterns of skeletal fractures in child abuse: systematic review

Evaluation of knowledge regarding shaken baby syndrome among parents and medical staff

BACKGROUND

Shaken baby syndrome (SBS), currently functioning as abusive head trauma (AHT), is a form of violence against children mainly under 2 years of age. The number of SBS might be underestimated, as many cases of violence remain unreported. The aim of the study was the evaluation of the state knowledge of the SBS phenomenon, its scale and diagnostic methods among parents, medical staff and medical students.

METHODS

A total of 639 people were examined: 39% of parents, 32.5% of medical staff members, and 28.5% of medical students; 82% were women. The average age was 34.9±9.78 years, and 70% of them had children. The research tool was an anonymous survey. The 34 questions concerned numerous aspects of violence against children as well as knowledge about SBS.

RESULTS

According to 90% of the interviewees shaking a baby may be dangerous but 43% have never heard about shaken baby syndrome. Eighty-eight percent of responders stated that "SBS is a form of violence," but only 57% realize that one-time shaking can lead to death and only 19% indicated men as aggressors. Sixteen percent of medical staff members did not know how long it takes for the consequences of shaking a baby to be revealed.

CONCLUSIONS

Majority of the medical staff members working with children have never heard about SBS. Only half of the surveyed understands the connection of shaking with vision loss or child's death. Among the long-term consequences of shaking a baby, the greatest knowledge concerns emotional consequences of shaking.

Imaging of Abusive Trauma

"Shaken baby syndrome" is a term often used by the physicians and public to describe abusive trauma inflicted on infants and young children. Advances in the understanding of the mechanisms and the associated clinical spectrum of injury has lead us to modify our terminology and address it as "abusive trauma" (AT). Pediatric abusive head trauma is defined as an injury to the skull or intracranial contents of an infant or a young child (< 5 y age) due to inflicted blunt impact and/or violent shaking. This chapter focuses on the imaging aspects of childhood abusive trauma along with a brief description of the mechanism and pathophysiology of abusive injury. The diagnosis of AT is not always obvious, and abusive injuries in many infants may remain unrecognized. Pediatricians should be cognizant of AT since pediatricians play a crucial role in the diagnosis, management and prevention of AT.

Child abuse and fabricated or induced illness in the ENT setting: a systematic review

BACKGROUND

Child maltreatment is persistently under-recognised. Given that a third of maltreated children may return with serious or fatal injuries, it is imperative that otolaryngologists who are in frequent contact with children are able to detect maltreatment at first presentation.

OBJECTIVE OF REVIEW

This review aims to identify ENT injuries, signs or symptoms that are indicative of physical abuse or fabricated or induced illness (child maltreatment).

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

An all-language search, developed in Medline Ovid and consisting of 76 key words, was conducted of published and grey literature across 10 databases from inception to July 2015, for primary observational studies involving children aged <18 years.

EVALUATION METHOD

Each relevant article underwent two independent reviews with full critical appraisal, applying strict quality standards.

RESULTS

Of the 2448 studies identified and screened, 371 underwent full review, resulting in 38 included studies that detailed 122 maltreated children. Pharyngeal perforations (n = 20) were the most frequent abusive ENT injury, predominantly affecting neonates and infants, presenting with dysphagia, drooling, haemoptysis and surgical emphysema. At least 52% of children with abusive pharyngeal injuries had additional co-existent injuries. The majority of ear injuries were inflicted to the external ear (n = 11) and included auricular deformity, abrasions, petechiae, lacerations and burns. Fabricated or induced illness cases presented most commonly with recurrent, unexplained otorrhoea or ENT lesions that failed to heal despite appropriate therapy.

CONCLUSIONS

All clinicians should be familiar with the signs of child maltreatment. Pharyngeal injuries, or injuries to the external ear, presenting in young children without an explicit history of witnessed injury should prompt a child protection referral for full evaluation. Likewise, children who present with recurrent, or apparently intractable symptoms and signs despite appropriate treatment, should raise the possibility of fabricated or induced illness, and discussion with a child protection specialist is advised. Early recognition of possible child maltreatment and instigation of appropriate safeguarding measures are essential to prevent repetition and escalation of injury. This is of paramount importance to otolaryngologists, who have the potential to identify these children in their practice.

The etiology and significance of fractures in infants and young children: a critical multidisciplinary review

This paper addresses significant misconceptions regarding the etiology of fractures in infants and young children in cases of suspected child abuse. This consensus statement, supported by the Child Abuse Committee and endorsed by the Board of Directors of the Society for Pediatric Radiology, synthesizes the relevant scientific data distinguishing clinical, radiologic and laboratory findings of metabolic disease from findings in abusive injury. This paper discusses medically established epidemiology and etiologies of childhood fractures in infants and young children. The authors also review the body of evidence on the role of vitamin D in bone health and the relationship between vitamin D and fractures. Finally, the authors discuss how courts should properly assess, use, and limit medical evidence and medical opinion testimony in criminal and civil child abuse cases to accomplish optimal care and protection of the children in these cases.

The radiologist's role in child abuse: imaging protocol and differential diagnosis

Child abuse or nonaccidental trauma is a major problem worldwide; in Spain, there are about 12,000 victims per year. The detection of specific lesions or findings that are incongruent with the reported mechanism of trauma mean that radiologists are often the physician responsible for sounding the alarm in cases of abuse. The triad consisting of subdural hematoma, metaphyseal fracture, and posterior rib fractures is very characteristic of the battered child syndrome. The finding of acute and chronic lesions in the same patient is highly specific for nonaccidental trauma. Fractures of long bones in patients who have yet begun to walk should also alert to possible child abuse. Lesions that are highly specific for abuse, such as classic metaphyseal fractures or posterior rib fractures, can be difficult to demonstrate radiographically and are usually clinically occult. The American College of Radiology (ACR) protocols recommend obtaining three separate X-rays of each upper and lower limb. It is important to use X-ray systems that give high resolution images with low kilovoltage (50-70 kvp) and appropriate milliamperage. A skeletal survey consisting of a series of images collimated to each body region is recommended for all children under the age of two years in whom abuse is suspected. A follow-up skeletal survey about two weeks after the initial survey is useful for detecting new fractures and for assessing the consolidation of others, which helps in dating the lesions. Head injuries are the leading cause of death in abused children. Although computed tomography is the first neuroimaging technique in nonaccidental trauma, magnetic resonance imaging of the head can better characterize the lesions seen on computed tomography and can help to estimate the age of the lesions.

Animal Abuse and Interpersonal Violence: The Cruelty Connection and Its Implications for Veterinary Pathology

The role of the veterinary forensic pathologist in the investigation of animal abuse or neglect can go beyond documenting the condition of animals presented as evidence. Although animal cruelty is a moral concern and a crime in itself, law enforcement response to such crimes is often enhanced by the recognition that crimes against animals can be both indicators of other ongoing crimes against people and predictors of the potential for interpersonal violence. An understanding of common motives underlying animal cruelty can aid the pathologist in asking appropriate questions. The authors review the forms of pathology evidence commonly seen in various presentations of animal cruelty. Understanding these forms of evidence can help the pathologist describe findings that can be significant for assessing the potential risks the alleged perpetrator may pose to other animals and humans.

The epidemiology of fractures in infants--Which accidents are preventable?

INTRODUCTION

In children, fractures have a huge impact on the health care system. In order to develop effective prevention strategies exact knowledge about the epidemiology of fractures is mandatory. This study aims to describe clinical and epidemiological data of fractures diagnosed in infants.

METHODS

A retrospective analysis of all infants (children<1 year of age) presenting with fractures in an 11 years period (2001-2011) was performed. Information was obtained regarding the location of the fractures, sites of the accident, circumstances and mechanisms of injury and post-injury care.

RESULTS

248 infants (54% male, 46% female) with a mean age of 7 months presented with 253 fractures. In more than half of the cases skull fractures were diagnosed (n=151, 61%). Most frequently the accidents causing fractures happened at home (67%). Falls from the changing table, from the arm of the care-giver and out of bed were most commonly encountered (n=92, 37%). While the majority of skull fractures was caused from falls out of different heights, external impacts tended to lead to fractures of the extremities. 6 patients (2%) were victims of maltreatment and sustained 10 fractures (2 skull fractures, 4 proximal humeral fractures, 2 rib fractures, and 2 tibial fractures).

CONCLUSION

Falls from the changing table, the arms of the caregivers and out of bed caused the majority of fractures (especially skull fracture) in infants. Therefore, awareness campaigns and prevention strategies should focus on these mechanisms of accident in order to decrease the rate of fractures in infants.

A Systematic Review of the Probability of Asphyxia in Children Aged <2 Years with Unexplained Epistaxis

OBJECTIVE

To determine the proportion of children aged <2 years who have been asphyxiated presenting with epistaxis in the absence of trauma or medical explanation and to identify the characteristics of the clinical presentation indicative of asphyxiation.

STUDY DESIGN

An all-language systematic review was conducted by searching 10 databases from 1900 to 2015 and gray literature to identify high-quality studies that included children with epistaxis aged <2 years (alive or dead) with explicit confirmation of intentional or unintentional asphyxiation (upper airway obstruction). Studies of traumatic or pathological epistaxis were excluded. For each comparative study, the proportion of children presenting with epistaxis that were asphyxiated is reported with 95% CI.

RESULTS

Of 2706 studies identified, 100 underwent full review, resulting in 6 included studies representing 30 children with asphyxiation-related epistaxis and 74 children with non-asphyxiation-related epistaxis. The proportion of children presenting with epistaxis that had been asphyxiated, reported by 3 studies, was between 7% and 24%. Features associated with asphyxiation in live children included malaise, altered skin color, respiratory difficulty, and chest radiograph abnormalities. There were no explicit associated features described among those children who were dead on arrival.

CONCLUSION

There is an association between epistaxis and asphyxiation in young children; however, epistaxis does not constitute a diagnosis of asphyxia in itself. In any infant presenting with unexplained epistaxis, a thorough investigation of etiology is always warranted, which must include active exploration of asphyxia as a possible explanation.

Gray cases of child abuse: Investigating factors associated with uncertainty

Research in child abuse pediatrics has advanced clinicians' abilities to discriminate abusive from accidental injuries. Less attention, however, has been paid to cases with uncertain diagnoses. These uncertain cases - the "gray" cases between decisions of abuse and not abuse - represent a meaningful challenge in the practice of child abuse pediatricians. In this study, we describe a series of gray cases, representing 17% of 134 consecutive children who were hospitalized at a single pediatric hospital and referred to a child abuse pediatrician for concerns of possible abuse. Gray cases were defined by scores of 3, 4, or 5 on a 7-point clinical judgment scale of the likelihood of abuse. We evaluated details of the case presentation, including incident history, patient medical and developmental histories, family social histories, medical studies, and injuries from the medical record and sought to identify unique and shared characteristics compared with abuse and accidental cases. Overall, the gray cases had incident histories that were ambiguous, medical and social histories that were more similar to abuse cases, and injuries that were similar to accidental injuries. Thus, the lack of clarity in these cases was not attributable to any single element of the incident, history, or injury. Gray cases represent a clinical challenge in child abuse pediatrics and deserve continued attention in research.

Comparing corporal punishment and children's exposure to violence between caregivers: Towards better diagnosis and prevention of intrafamilial physical abuse of children

Any intervention involving child victims of intrafamilial abuse must take the alleged underlying motives for the abuse into account. The aim of this study is to further our understanding of intrafamilial physical abuse of children, by comparing its various aspects while considering the alleged underlying motives. A preliminary sample of 1656 cases of alleged physical abuse in the northern region of Portugal was analysed, with two main motives being identified: corporal punishment (CP) (G1 = 927) and exposure to violence between caregivers (EVC) (G2 = 308). Statistically significant differences were found between the two motives (p < 0.05) for the following variables: (1) age of the alleged victims, (2) sex of the alleged abuser, (3) risk factors affecting the alleged abuser, (4) abuser/victim relationship, (5) injury-producing mechanism, (6) time between last abuse and forensic medical examination and (7) location of injuries. Evidence-based knowledge of these differences may help in accurate diagnosis by doctors (particularly forensic physicians) and prevention of this type of violence through support strategies (including tertiary prevention strategies).

Paediatric femur fractures at the emergency department: accidental or not?

Only a small proportion of all paediatric fractures is caused by child abuse or neglect, especially in highly prevalent long bone fractures. It can be difficult to differentiate abusive fractures from non-abusive fractures. This article focuses on femoral fractures in young children. Based on three cases, this article presents a forensic evidence-based approach to differentiate between accidental and non-accidental causes of femoral fractures. We describe three cases of young children who were presented to the emergency department because of a suspected femur fracture. Although in all cases, the fracture had a similar location and appearance, the clinical history and developmental stage of the child led to three different conclusions. In the first two cases, an accidental mechanism was a plausible conclusion, although in the second case, neglect of parental supervision was the cause for concern. In the third case, a non-accidental injury was diagnosed and appropriate legal prosecution followed. Any doctor treating children should always be aware of the possibility of child abuse and neglect in children with injuries, especially in young and non-mobile children presenting with an unknown trauma mechanism. If a suspicion of child abuse or neglect arises, a thorough diagnostic work-up should be performed, including a full skeletal survey according to the guidelines of the Royal College of Radiologists and the Royal College of Paediatrics and Child Health. In order to make a good assessment, the radiologist reviewing the skeletal survey needs access to all relevant clinical and social information.

Abusive head trauma and accidental head injury: a 20-year comparative study of referrals to a hospital child protection team

AIM

To describe children referred for suspected abusive head trauma (AHT) to a hospital child protection team in Auckland, New Zealand.

METHODS

Comparative review of demographics, histories, injuries, investigations and diagnostic outcomes for referrals under 15 years old from 1991 to 2010.

RESULTS

Records were available for 345 children. Referrals increased markedly (88 in the first decade, 257 in the second), but the diagnostic ratio was stable: AHT 60%, accidental or natural 29% and uncertain cause 11%. The probability of AHT was similar regardless of socio-economic status or ethnicity. In children under 2 years old with accidental head injuries (75/255, 29%) or AHT (180/255, 71%), characteristics of particular interest for AHT included no history of trauma (88/98, 90%), no evidence of impact to the head (84/93, 90%), complex skull fractures with intracranial injury (22/28, 79%), subdural haemorrhage (160/179, 89%) and hypoxic ischaemic injury (38/39, 97%). In children over 2 years old, these characteristics did not differ significantly between children with accidental head injuries (21/47, 45%) and AHT (26/47, 55%). The mortality of AHT was higher in children over 2 years old (10/26, 38%) than under 2 years (19/180, 11%).

CONCLUSIONS

The striking increase in referrals for AHT probably represents increasing incidence. The decision to refer a hospitalised child with a head injury for assessment for possible AHT should not be influenced by socio-economic status or ethnicity. Children over 2 years old hospitalised for AHT are usually injured by mechanisms involving impact and should be considered at high risk of death.

Evaluation for Occult Fractures in Injured Children

OBJECTIVES

To examine variation across US hospitals in evaluation for occult fractures in (1) children <2 years old diagnosed with physical abuse and (2) infants <1 year old with injuries associated with a high likelihood of abuse and to identify factors associated with such variation.

METHODS

We performed a retrospective study in children <2 years old with a diagnosis of physical abuse and in infants <1 year old with non-motor vehicle crash-related traumatic brain injury or femur fractures discharged from 366 hospitals in the Premier database from 2009 to 2013. We examined across-hospital variation and identified child- and hospital-level factors associated with evaluation for occult fractures.

RESULTS

Evaluations for occult fractures were performed in 48% of the 2502 children with an abuse diagnosis, in 51% of the 1574 infants with traumatic brain injury, and in 53% of the 859 infants with femur fractures. Hospitals varied substantially with regard to their rates of evaluation for occult fractures in all 3 groups. Occult fracture evaluations were more likely to be performed at teaching hospitals than at nonteaching hospitals (all P < .001). The hospital-level annual volume of young, injured children was associated with the probability of occult fracture evaluation, such that hospitals treating more young, injured patients were more likely to evaluate for occult fractures (all P < .001).

CONCLUSIONS

Substantial variation in evaluation for occult fractures among young children with a diagnosis of abuse or injuries associated with a high likelihood of abuse highlights opportunities for quality improvement in this vulnerable population.

Mimics of child abuse: Can choking explain abusive head trauma?

Choking is one of the alternative explanations of abusive head trauma in children that have been offered in courtroom testimony and in the media. Most of these explanations - including choking - are not scientifically supported. This article highlights four points. (1) The origins of choking as an explanation for intracranial and retinal hemorrhages are speculative. (2) Choking has been used in high profile court testimony as an explanation for the death of a child thought to have been abused. (3) A case report that proposes choking as an alternative explanation for the death of a child diagnosed with abusive head trauma includes omissions and misrepresentations of facts. (4) There was a decision by the editor of the journal that published the case report that it was not necessary to include all the facts of the case; moreover, the editor indicated that facts are not required when presenting an alternative explanation. The use of scientifically unsupported alternative explanations for abusive head trauma based on inaccurate and biased information constitutes further victimization of the abused child and represents a travesty of justice.

Abusive head trauma: a review of the evidence base

OBJECTIVE

The purpose of this article is to review the constellation of findings of abusive head trauma, which may be accompanied by injuries to the appendicular and axial skeleton, brain and spinal cord, and retina. Additional common features include skin and soft-tissue injury, visceral findings, and evidence of oral trauma.

CONCLUSION

The evidence base for abusive head trauma encompasses diverse disciplines, including diagnostic imaging, pathology, pediatrics, biomechanics, ophthalmology, epidemiology, and orthopedics. When the varied sources of evidence are pieced together and taken in toto, abusive head trauma is often readily differentiated from alternative explanations of an infant's injuries.

The evaluation of suspected child physical abuse

Child physical abuse is an important cause of pediatric morbidity and mortality and is associated with major physical and mental health problems that can extend into adulthood. Pediatricians are in a unique position to identify and prevent child abuse, and this clinical report provides guidance to the practitioner regarding indicators and evaluation of suspected physical abuse of children. The role of the physician may include identifying abused children with suspicious injuries who present for care, reporting suspected abuse to the child protection agency for investigation, supporting families who are affected by child abuse, coordinating with other professionals and community agencies to provide immediate and long-term treatment to victimized children, providing court testimony when necessary, providing preventive care and anticipatory guidance in the office, and advocating for policies and programs that support families and protect vulnerable children.

Risk factors for long-bone fractures in children up to 5 years of age: a nested case-control study

AIM

To investigate risk factors for first long-bone fractures in children up to 5 years old in order to provide evidence about which families could benefit from injury prevention interventions.

METHODS

Population-based matched nested case-control study using The Health Improvement Network, a UK primary care research database, 1988-2004. Maternal, household and child risk factors for injury were assessed among 2456 children with long-bone fractures (cases). 23,661 controls were matched to cases on general practice. Adjusted ORs and 95% CIs were estimated using conditional logistic regression.

RESULTS

Fractures of long-bones were independently associated with younger maternal age and higher birth order, with children who were the fourth-born in the family, or later, having a threefold greater odds of fracture compared to first-born children (adjusted OR 3.12, 95% CI 2.08 to 4.68). Children over the age of 1 year had a fourfold (13-24 months, adjusted OR 4.09 95% CI 3.51 to 4.76) to fivefold (37+ months, adjusted OR 4.88 95% CI 4.21 to 5.66) increase in the odds of a long-bone fracture compared to children aged 0-12 months. Children in families with a history of maternal alcohol misuse had a raised odds of long-bone fracture (adjusted OR 2.33, 95% CI 1.13 to 4.82) compared to those with no documented history.

CONCLUSIONS

Risk factors for long-bone fractures in children less than 5 years old included age above 1 year, increasing birth order, younger maternal age and maternal alcohol misuse. These risk factors should be used to prioritise families and communities for injury prevention interventions.

Nonaccidental trauma: guidance for nurses in the pediatric intensive care unit

Each year thousands of children are hospitalized for traumatic injuries associated with physical abuse. Nurses in the pediatric intensive care unit must be knowledgeable and skilled in caring for the physical, psychological, emotional, social, and developmental needs of such children and their families. This article provides direction for pediatric nurses working in the critical care setting. Specifically, it describes the nursing care of children in a pediatric intensive care unit where the mechanism of nonaccidental injury is blunt force to the head, abdomen, or musculoskeletal system, based on standards put forth by the American Association of Critical-Care Nurses.

Evaluation of child maltreatment in the emergency department setting: an overview for behavioral health providers

Emergency providers are confronted with medical, social, and legal dilemmas with each case of possible child maltreatment. Keeping a high clinical suspicion is key to diagnosing latent abuse. Child abuse, especially sexual abuse, is best handled by a multidisciplinary team including emergency providers, nurses, social workers, and law enforcement trained in caring for victims and handling forensic evidence. The role of the emergency provider in such cases is to identify abuse, facilitate a thorough investigation, treat medical needs, protect the patient, provide an unbiased medical consultation to law enforcement, and provide an ethical testimony if called to court.

A feasibility study of 60 consecutive patients operated for unstable thoracic cage

Background

About 10% of adult patients in high-energy trauma sustain multiple rib fractures. Some of these patients suffer from flail chest leading to respiratory insufficiency. During last years interest and results for operative treatment has improved. The literature today all show positive results for surgical versus conservative treatment, specifically with regard to time spent in mechanical ventilator, complication rates and length of hospital stay.

Methods

Between September 2010 and July 2012, 60 patients with flail chest or multiple rib-fractures resulting in unstable thoracic cage were operated. 16 women and 44 men with an age between 19-86 years (mean 57). We used modern fracture techniques with plates and intramedullary splint. Thoracotomy was performed and lung lacerations were debrided (11/60). Time spent in ventilator, complications and other adverse effects was studied. The operated cohort was compared to results from six previous years, when none was operated for that diagnose (153 patients).

Results

There is a significant correlation between Injury Severity Score (ISS) and time spent in ventilator both for patients operated and not operated (p< 0,01). The mean time in ventilator was 9,01 days for not operated patients compared to 2,7 for the operated (p<0,0001). No clear pneumonias were found. We had two deaths during the acute period. The infection rate was low.

Conclusions

Open reduction and internal fixation is a safe method to treat the unstable thoracic cage with multiple rib fractures and flail chest. Complication are few. The treatment time in mechanical ventilator is significant decreased. The operative treatment is probably cost effective and can be recommended. Knowledge in thoracic surgery and modern fracture surgery is needed. This is a therapeutic consecutive, level III, cohort study with historical controls.

Imaging abusive head trauma: why use both computed tomography and magnetic resonance imaging?

Abusive head trauma is the leading cause of death in child abuse cases. The majority of victims are infants younger than 1 year old, with the average age between 3 and 8 months, although these injuries can be seen in children up to 5 years old. Many victims have a history of previous abuse and the diagnosis is frequently delayed. Neuroimaging is often crucial for establishing the diagnosis of abusive head trauma as it detects occult injury in 37% of cases. Several imaging patterns are considered to be particularly associated with abusive head trauma. The presence of subdural hematoma, especially in multiple locations, such as the interhemispheric region, over the convexity and in the posterior fossa, is significantly associated with abusive head trauma. Although CT is the recommended first-line imaging modality for suspected abusive head trauma, early MRI is increasingly used alongside CT because it provides a better estimation of shear injuries, hypoxic-ischemic insult and the timing of lesions. This article presents a review of the use and clinical indications of the most pertinent neuroimaging modalities for the diagnosis of abusive head trauma, emphasizing the newer and more sensitive techniques that may be useful to better characterize the nature and evolution of the injury.

Imaging of skeletal injuries associated with abusive head trauma

Skeletal injuries are commonly encountered in infants and young children with abusive head trauma. Although certain patterns of intracranial injury suggest abuse, none are diagnostic. Therefore demonstration of associated unsuspected skeletal injuries has important implications, particularly when highly specific fractures are present. Skull fractures are commonly associated with intracranial injury, but no fracture pattern is indicative of physical abuse. Other skeletal injuries including classic metaphyseal lesions and rib, spine and scapular fractures are strong predictors of abusive head trauma in infants with intracranial injury. It is mandatory to perform rigorous skeletal surveys in infants and young children with clinical and neuroimaging findings concerning for abusive head trauma.

A proposed scheme for classifying pediatric rib head fractures using case examples

Pediatric rib head fractures are typically described as "posterior" or "costovertebral," terms lacking specificity. To resolve this issue, a scheme was developed to describe the location of rib head fractures observed in a pediatric forensic population. The scheme uses three anatomical landmarks, terminus (tip), tubercle, and costovertebral articular surface to divide the rib head into two subregions, costovertebral and costotransverse. Examples of five cases of infants with rib head fractures are presented using this scheme. Forty-eight rib head fractures were observed in these infants with the following frequencies: 56% (three infants) at the terminus; 21% (three infants) in the costovertebral subregion; 21% (one infant) at the costovertebral articular facet; and 2% (one infant) in the costotransverse subregion. Due to the small number of cases assessed, statistical analyses could not be performed; however, the data demonstrate the variation in distribution of pediatric rib head fractures.

Pattern of fractures in non-accidental injuries in the pediatric population in Singapore

BACKGROUND

Fractures as a result of non-accidental injuries (NAI) are not uncommon among children. The purpose of our study was to describe the incidence, demographic characteristics, and associated risk factors in patients with NAI in a multiethnic Asian cohort.

METHODS

A retrospective record review of patients admitted to our hospital between September 2007 and 2009 with the diagnosis of NAI was conducted.

RESULTS

A total of 978 children were reported with suspicion of NAI. Among them, 570 patients (58.28%) were diagnosed with NAI. Fractures were observed in 35 children (6.14%). NAI fractures were highest among female infants (73.3%). The biological father was the most common known perpetrator of NAI (n = 155, 29.0%). The most common perpetrator sadly remained unknown (n = 14, 40%). All NAI fractures were closed (n = 35, 6.14%), and the most commonly affected bone was the humeral shaft (n = 10, 28.57%) with an oblique configuration. Age < 1 year and parental divorce were significant risk factors associated with these fractures.

CONCLUSIONS

The skeletal injury pattern and risk factors highlighted in our study will help treating physicians identify patients susceptible to NAI, as many of these patients are young and vulnerable. Protective measures can be initiated early by recognizing these injuries and preventing further physical and psychological harm to the child.

Forensic medical evaluations of child maltreatment: a proposed research agenda

Physicians play an important role in the forensic evaluation of suspected child abuse and neglect. There has been considerable progress in the medical field, helping distinguish findings related to maltreatment from other conditions or circumstances. Nevertheless, important questions remain. This article covers several of these questions and proposes a research agenda concerning five main topics: sexual abuse, neglect, fractures, abusive head trauma, and physicians work in interdisciplinary settings. The suggestions are hardly inclusive, but offer suggestions the authors think are priorities, and ones that research could reasonably address. By providing some background to gaps in our knowledge, this paper should be of interest to a broader audience than just medical professionals.

Frequency of intrathoracic injuries in children younger than 3 years with rib fractures

BACKGROUND

Research documents that among children admitted to trauma intensive care units the number of rib fractures sustained indicates the child's likelihood of having and severity of intrathoracic injury. This has been misused in court to argue that children with multiple rib fractures who lack intrathoracic injury have abnormal bone fragility rather than inflicted injury.

OBJECTIVE

To determine frequency of intrathoracic injuries in children younger than 3 years with rib fractures in cases of child abuse and accidental trauma.

MATERIALS AND METHODS

We conducted a retrospective review of rib fractures caused by documented abuse or accidents from 2003 to 2010 in children treated at Seattle Children's Hospital and Harborview Medical Center. A senior pediatric radiologist and radiology fellow independently reviewed the imaging. Children with bone demineralization were excluded. Descriptive and simple comparative statistics were used.

RESULTS

Seventy-two percent (47/65) of infants and toddlers with rib fractures were abused. Abused children had more rib fractures than accidentally injured children (5.55 vs. 3.11, P = 0.012). However intrathoracic injuries as a whole (55.6% vs. 12.8%, P < 0.001) and individual types of intrathoracic injuries were more common with accidents. Rates of other thoracic cage injuries did not differ substantially (27.8% accidents vs. 12.8% abuse, P = 0.064). Intracranial and intra-abdominal injuries and skull fractures were equally frequent, but other extrathoracic fractures were more common with abuse (70.2% vs. 16.7%, P < 0.001).

CONCLUSIONS

Abused infants and toddlers have fewer intrathoracic injuries but more rib fractures than accidentally injured peers. This likely reflects different injury mechanics. Lack of intrathoracic injuries in abused children with rib fractures does not imply bone fragility.

Alagille syndrome case report: implications for forensic pathology and anthropology

This case report offers a multidisciplinary interpretation of the violent death of a 4-year-old girl suffering from Alagille syndrome who died after a low-height fall that resulted in temporal bone fracture and a large epidural hematoma. The article evidences the macroscopical and microscopical characteristics of the syndrome, focusing especially on the skeletal findings that emerged during autopsy. In the case report, distinction is made between a possible accidental or non-accidental nature of the injuries and the characteristics of the injury have been interpreted in the light of the existing data on Alagille syndrome. In conclusion, the death was documented as accidental since abnormalities in the skeletal system evidenced during autopsy have predisposed the death of the child albeit through a very mild head trauma. The case report evidences the importance of studying features of skull macro- and microstructure in patients with Alagille syndrome, which have been, until now, underreported in literature and which might contribute to fracture vulnerability in these patients. Although rare, Alagille syndrome is a condition that should be known to forensic medicine practitioners and whose features and peculiarities must be taken into consideration in pediatric autopsy and suspected child abuse cases.

A case of an infant suffered from a fatal scald injury - validity and limitations of postmortem CT imaging

A 9months-old infant has died of scald burn by the hot water from the fallen electric pot at home. Postmortem computed tomography (CT) scanning prior to autopsy contributed to exclude the possibilities of old and new bone fractures or hidden massive hemorrhages. This procedure helped the pathologists to avoid dissecting all the extremities, which is time-consuming, laborious and often hurtful to the innocent parents of the deceased. On the other hand it did not successfully show the distribution of the scald burn injury on the skin, which reminded us of the importance of external examination even when the whole-body CT is performed. The manner of death was considered to be accident since the cause of death was burn shock and there was no significant evidence suggesting child abuse. Scene investigation and reproductive experiment have revealed that there was a structural problem in the lid of the pot, which comes off very easily in a certain condition. In order to prevent a similar accident, report of the case to the manufacturer is essential for the improvement of the apparatus. This case, however, has been remained to be unreported because of the confidentiality of the investigative information in judicial autopsy. Finally, we recommend a partial revision of the reporting system in Japan to prevent the recurrence of such tragic accidents.

Cardiopulmonary resuscitation (CPR)-related posterior rib fractures in neonates and infants following recommended changes in CPR techniques

Posterior rib fractures are highly indicative of non-accidental trauma (NAT) in infants. Since 2000, the "two-thumbs" technique for cardiopulmonary resuscitation (CPR) of newborns and infants has been recommended by the American Heart Association (AHA). This technique is similar to the grip on an infant's thorax while shaking. Is it possible that posterior rib fractures in newborns and infants could be caused by the "two-thumbs" technique? Using computerized databases from three German children's hospitals, we identified all infants less than 12 months old who underwent professional CPR within a 10-year period. We included all infants with anterior-posterior chest radiographs taken after CPR. Exclusion criteria were sternotomy, osteopenia, various other bone diseases and NAT. The radiographs were independently reviewed by the Chief of Pediatric Radiology (MB) and a Senior Pediatrician, Head of the local Child Protection Team (IF). Eighty infants with 546 chest radiographs were identified, and 50 of those infants underwent CPR immediately after birth. Data concerning the length of CPR was available for 41 infants. The mean length of CPR was 11min (range: 1-180min, median: 3min). On average, there were seven radiographs per infant. A total of 39 infants had a follow-up radiograph after at least 10 days. No rib fracture was visible on any chest X-ray. The results of this study suggest rib fracture after the use of the "two-thumbs" CPR technique is uncommon. Thus, there should be careful consideration of abuse when these fractures are identified, regardless of whether CPR was performed and what technique used. The discovery of rib fractures in an infant who has undergone CPR without underlying bone disease or major trauma warrants a full child protection investigation.

A critical review of the classic metaphyseal lesion: traumatic or metabolic?

OBJECTIVE

The purpose of this study was to review the hypothesis that classic metaphyseal lesions represent traumatic changes in abused infants and compare these lesions with healing rickets.

MATERIALS AND METHODS

Using a PubMed search, a multidisciplinary team reviewed studies that reported the histopathologic correlation of classic metaphyseal lesions. Selective studies of growth plate injury and rickets were cross-referenced.

RESULTS

Nine identified classic metaphyseal lesion studies were performed by the same principal investigator. Control subjects were inadequate. Details of abuse determination and metabolic bone disease exclusion were lacking. The presence of only a single radiology reviewer prevented establishment of interobserver variability. Microscopy was performed by two researchers who were not pathologists. Classic metaphyseal lesions have not been experimentally reproduced and are unrecognized in the accidental trauma literature. The proposed primary spongiosa location is inconsistent with the variable radiographic appearances. Classic metaphyseal lesions were not differentiated from tissue processing artifacts. Bleeding and callus were uncommon in spite of the vascular nature of the metaphysis. The conclusion that excessive hypertrophic chondrocytes secondary to vascular disruption were indicative of fracture healing contradicts the paucity of bleeding, callus, and periosteal reaction. Several similarities exist between classic metaphyseal lesions and healing rickets, including excessive hypertrophic chondrocytes. "Bucket-handle" and "corner fracture" classic metaphyseal lesions resemble healing rickets within the growth plate and the perichondrial ring, respectively. The age of presentation was more typical of bone fragility disorders, including rickets, than reported in prior child abuse series.

CONCLUSION

The hypothesis that classic metaphyseal lesions are secondary to child abuse is poorly supported. Their histologic and radiographic features are similar to healing infantile rickets. Until classic metaphyseal lesions are experimentally replicated and independently validated, their traumatic origin remains unsubstantiated.

A brief history of fatal child maltreatment and neglect

Child abuse encompasses four major forms of abuse: physical abuse, sexual abuse, psychological abuse, and neglect. The United States retains one of the worst records of child abuse in the industrialized world. It has also been determined that a large portion of these cases are missed and go undocumented in state and federal reporting agencies. In addition, disparate risk factors have been identified for physical abuse and neglect cases, but substance abuse has been found to be a significant factor in all forms of abuse. Fatal child maltreatment and neglect investigations require a multi-pronged and multidisciplinary approach requiring the coordination and information gathering from various agencies. A major difficulty in determining the accidental or non-accidental nature of these cases is that the account surrounding the events of the death of child is acquired from the caretaker. In this review, we outline common diagnostic characteristics and patterns of non-accidental injuries and neglect as a result of nutritional deprivation.

Skeletal trauma in child abuse

Fractures and other skeletal injuries are common in childhood. Most are the result of falls, motor vehicle accidents, and other forms of accidental trauma. However, skeletal trauma is present in a significant number of abused children. Age and developmental abilities are key components in raising clinical suspicion for child abuse. Children who are unable to provide their own history because of age or developmental delay require increased attention. Younger children are more likely to have abusive fractures, whereas accidental fractures increase with age and developmental abilities. The consequences of missing abuse are high because children returned to their homes without intervention are likely to face further abuse and have an increased mortality risk. Because of the potentially high cost of undiagnosed child abuse, diagnosis of a skeletal injury is incomplete without diagnosing its etiology. All health providers for children should be able to recognize patterns of skeletal injury secondary to abusive trauma and understand the process for initiating Child Protective Services (CPS) investigations when necessary. Although they can occur accidentally, fractures in nonmobile children should always increase the clinician's concern for abusive trauma. In light of the significant consequences for children when abuse is missed by a primary care provider, abuse should be on the differential diagnosis for all presenting childhood injuries.

Characteristics of child dental neglect: a systematic review

OBJECTIVE

Neglect of a child's oral health can lead to pain, poor growth and impaired quality of life. In populations where there is a high prevalence of dental caries, the determination of which children are experiencing dental neglect is challenging. This systematic review aims to identify the features of oral neglect in children.

METHODS

Fifteen databases spanning 1947-2012 were searched; these were supplemented by hand searching of 4 specialist journals, 5 websites and references of full texts. Included: studies of children 0-18 years with confirmed oral neglect undergoing a standardised dental examination; excluded: physical/sexual abuse. All relevant studies underwent two independent reviews (+/- 3rd review) using standardised critical appraisal.

RESULTS

Of 3863 potential studies screened, 83 studies were reviewed and 9 included (representing 1595 children). Features included: failure or delay in seeking dental treatment; failure to comply with/complete treatment; failure to provide basic oral care; co-existent adverse impact on the child e.g. pain and swelling. Two studies developed and implemented 'dental neglect' screening tools with success. The importance of Quality of Life tools to identify impact of neglected dental care are also highlighted.

CONCLUSIONS

A small body of literature addresses this topic, using varying definitions of neglect, and standards of oral examination. While failure/delay in seeking care with adverse dental consequences were highlighted, differentiating dental caries from dental neglect is difficult, and there is a paucity of data on precise clinical features to aid in this distinction.

CLINICAL SIGNIFICANCE

Diagnosing dental neglect can be challenging, influencing a reluctance to report cases. Published evidence does exist to support these referrals when conditions as above are described, although further quality case control studies defining distinguishing patterns of dental caries would be welcome.

CT of the neonatal head

Computed tomography (CT) is used less often than other techniques on neonatal units. However, in the acute setting, CT can be invaluable in diagnosing or excluding potentially life-threatening conditions and guiding initial management in neonates. Common indications for scanning include trauma, suspected non-accidental injury, infection, or an acute hypoxic or metabolic event. The aim of this review is to provide an overview of the normal neonatal head at CT and compare this to the common pathological abnormalities. Several key features of each condition will be highlighted. It is important to note that some pathological conditions can have overlapping features at CT and, therefore, the clinical history and additional investigations are also of key importance in determining the diagnosis.

Implementing scientific evidence to improve the quality of Child Protection

In contrast to other areas of medical practice, there was a lack of a clear, concise and accessible synthesis of scientific literature to aid the recognition and investigation of suspected child abuse, and no national training program or evidence based guidelines for clinicians. The project's aim was to identify the current scientific evidence for the recognition and investigation of suspected child abuse and neglect and to disseminate and introduce this into clinical practice. Since 2003 a comprehensive program of Systematic Reviews of all aspects of physical abuse, emotional abuse, and neglect of children, has been developed. Based on NHS Centre for Reviews and Dissemination standards, methodology was devised and reviewers trained. Dissemination was via peer reviewed publications, a series of leaflets highlighting key points in a Question and Answer format, and a website. To date, 21 systematic reviews have been completed, generating 28 peer reviewed publications, and six leaflets around each theme (eg fractures, bruising). More than 250,000 have been distributed to date. Our website generates more than 10,000 hits monthly. It hosts primary reviews that are updated annually, links to all included studies, publications, and detailed methodology. The reviews have directly informed five national clinical guidelines, and the first evidence based training in Child Maltreatment. Child abuse is every health practitioner's responsibility, and it is vital that the decisions made are evidence based, as it is expected in all other fields of medicine. Although challenging, this project demonstrates that it is possible to conduct high quality systematic reviews in this field. For the first time a clear concise synthesis of up to date scientific evidence is available to all practitioners in a range of accessible formats. This has underpinned high quality national guidance and training programs. It ensures all professionals have the appropriate knowledge base in this difficult and challenging field.

Cross-country comparison of victimisation-related injury admission in children and adolescents in England and Western Australia

Background

A single, standardised measure of victimisation-related (VR) injury admission in hospital administrative datasets could allow monitoring of preventive and response strategies and international comparisons of policy. Consistency of risk factors and incidence rates for a measure of victimisation-related injury in different countries with similar access to healthcare services would provide indirect evidence for measure validity.

Methods

Cohorts were derived from hospital administrative data for children aged less than 18 years who were admitted for acute injury to hospitals in England or Western Australia (WA) in 2000 to 2008. We compared the effects of age, sex and deprivation on the annual incidence of acute admission for VR injury defined by a cluster of ICD-10 codes reflecting characteristics that should alert clinicians to consider victimisation as a cause of injury. Four subcategories comprised codes specifically indicating child maltreatment, assault, undetermined cause, or adverse social circumstances.

Results

The incidence of VR injury followed a similar ‘J’-shaped association with age in both countries with increasing rates from 10 years onwards and peaks in infancy and in 16–17 year-olds. In both countries, rates increased with deprivation. Girls had lower rates than boys except in the 11–15 age group where girls had higher rates than boys in WA but not in England. Adjusted incidence rates were similar in both countries for children aged 3 to 15 years old, but were higher in WA compared with England in children under 3 years old and in those aged 16–17 years. Higher rates in WA in 16–17 year-olds were explained by more admissions coded for the subcategories of adverse social circumstances, and to a lesser extent, assault, than in England. Children less than 3 years old were more often coded specifically for maltreatment in WA than in England.

Conclusions

The similarities in risk factors and in the adjusted rates of victimisation-related injury admission in both countries suggest that the VR cluster of ICD-10 codes is measuring a similar underlying problem. Differential use of coding subcategories highlights the need to use the entire VR cluster for comparisons across settings.

Child abuse: review of the literature

Non-accidental injuries in children are an important cause of morbidity and mortality in this population. Fractures are the second most common clinical manifestation of child abuse. The fracture of the femur is associated in more than 60% of child abuse in children younger than 3 years. The objective was to review the literature on child abuse in the major databases and report a rare case of bilateral subtrochanteric femur fractures associated with unilaterall humeral fracture in a 28-day newborn. The orthopedic surgeon is often the first physician to evaluate these children, so a high degree of suspicion, and a physical examination and a detailed clinical history is mandatory when evaluating a newborn with musculoskeletal injuries.

Patterns of structural head injury in children younger than 3 years: a ten-year review of 519 patients

BACKGROUND

Abusive head injury is a major contributor to morbidity and mortality in infants and toddlers, but data comparing patterns of injury in corroborated accidental trauma and confessed child abuse are scarce.

METHODS

This is a retrospective review of head injuries with abnormal neuroimaging in children younger than 3 years during a 10-year period in Auckland, New Zealand. Histories were assumed to be true. Results were analyzed for incongruity then compared with data on confessed abuse and corroborated accidental injury.

RESULTS

Five hundred nineteen cases were analyzed. Most cases were congruent with the history, and their pattern was consistent with the literature on accidental head trauma in childhood. However, a spike of subdural hemorrhage was seen in the first 6 months of life, explained neither by mechanism nor by published data on birth trauma. The age distribution of retinal hemorrhage was also inconsistent with published data on birth trauma. In infants younger than 6 months, retinal and subdural hemorrhages were associated with the absence of a history of trauma. In older children (6 months-3 years), subdural hemorrhage was more common after minor falls (<1 m, 49%) than major falls (>2 m, 20%) (p = 0.002).

CONCLUSION

We conclude that when a young child (particularly an infant younger than 6 months) presents with traumatic intracranial pathology and either no history of trauma or a history of a minor fall, it must be seriously considered that the history is false.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Fractures in children younger than 18 months

Fractures in children younger than 18 months occur before the usual walking age. The prognosis is favourable across fracture types and circumstances of occurrence. The cause is obvious in obstetrical injuries, whose risk factors have been well documented. Diaphyseal fractures are easy to recognise, whereas challenges may arise with the diagnosis of physeal injuries. Fractures occurring after the neonate is discharged home may be due to accidental falls related to clumsiness on the part of the carers. Other possibilities, however, are child abuse and abnormal bone fragility. Thus, the aetiological diagnosis has major medical, social, and legal implications. Identifying the aetiology is often extremely difficult and benefits from the involvement of a multidisciplinary team. The literature review presented herein is designed to assist orthopaedic surgeons in the diagnosis and management of children with fractures before 18 months of age, in compliance with French legislation, which has undergone major changes over the last quarter century.