A descriptive study of accidental skeletal injuries and non-accidental skeletal injuries of child maltreatment

Pediatric skeletal injuries in emergency department; an alarm of child maltreatment in Egypt: A cross-sectional study

BACKGROUND

Child physical abuse, a type of child maltreatment (CM), poses a significant global public health concern. Nonaccidental fractures and soft tissue injuries, which encompass any action that directly or indirectly harms a child, are the primary indicators of physical abuse in children.

OBJECTIVE

This study aimed to investigate the prevalence, risk factors, and outcomes of accidental and nonaccidental skeletal fractures in a sample of Egyptian children.

METHODS

A cross-sectional analytical study was conducted between March 2022 and August 2022. A total of 156 children who presented with skeletal injuries and attended Mobarak Central Hospital were enrolled. Patients were subjected to full history taking, complete examination, and investigations. A structured questionnaire was administered to all the legal guardians.

RESULTS

Physical abuse was reported in 22.4 % of cases, while medical neglect was reported in 19.9 % of cases. The incidence of physical abuse was notably higher among children whose fathers were smokers and/or drug addicts (p ≤ 0.05). The most common form of physical abuse was hitting (94.3 %). Among skeletal injuries, fractures were predominant (94.3 %), primarily closed fractures associated with contusions. Fractures of the upper limb accounted for the highest incidence (94.3 %) of skeletal injuries, and 60 % of physically abused children experienced moderate-severity injuries.

CONCLUSION

The most common fracture observed in abused children is the upper limb fracture, typically involving a single bone. Clinicians should be more vigilant in suspecting abuse, even in cases where there is an isolated fracture, and advocate for the development of parental training programs.

Bone pathology mimicking non-accidental injury in a child - Bewildered by bones, case report and review of the literature

INTRODUCTION AND IMPORTANCE

Physical abuse of children is criminal conduct in the purview of medico-legal sciences and the confirmative diagnosis of 'child abuse' is imperative for further legal proceedings. Clinicians play a pivotal role in the protection of children by recognizing and reporting such cases and treating the victims of abuse.

PRESENTATION OF CASE

To the best of our knowledge, we present the first case report in literature where osteofibrous dysplasia resulted in a pathological fracture in a 10-month-old South-Asian child which resembled the picture of child abuse.

CLINICAL DISCUSSION

The challenges faced by clinicians in the process of analysis of presumed child abuse are numerous and careful formulation and elimination of medical conditions which may mimic non-accidental injury (NAI) is a must, prior to making an incontrovertible diagnosis.

CONCLUSION

The telltale signs of NAI such as soft tissue injuries and fractures in a victimized child should always be evaluated cautiously with the intent of excluding pathologies that may mimic them and the evidence in this regard is seldom in literature.

Fatal non-accidental injury in South Africa: A Gauteng hospital’s perspective on the incidence and fracture types in post-mortem skeletal surveys

Background

In its severest form, non-accidental injury (NAI) in children is fatal. South Africa has been reported to have double the global average of child homicides. Autopsy is the main investigation in fatal NAI with post-mortem skeletal surveys (PMSS) playing an adjunctive role. Whilst fracture patterns associated with NAI in living patients have been established, this has not been investigated in PMSS in South Africa.

Objectives

To determine the incidence and characteristics of fractures in suspected fatal NAI cases. To calculate the incidence of fractures according to high-, moderate- and low-specificity fracture locations for NAI.

Methods

A retrospective review of all PMSS performed between 01 January 2012 and 03 December 2018 was conducted at the Charlotte Maxeke Johannesburg Academic Hospital.

Results

Of the 73 PMSS, 33 (45.2%) demonstrated fractures. No statistical significance in sex was found: 38 (52.1%) were male and 35 (47.9%) were female (p > 0.05). The mean age of those who sustained fractures was 28 months (standard deviation [s.d.]: 21 months). A total of 115 fractures were sustained, of that the top five bones fractured were the ribs 37 (32.2%), parietal bone 13 (11.3%), ulna 13 (11.3%), femur 13 (11.3%), and radius 11 (9.6%). High-specificity fracture locations accounted for 40/133 (30.1%).

Conclusion

The fracture types in PMSS were similar to those in live skeletal surveys. Our study’s fracture rate was higher in comparison to international studies. The PMSS is a valuable adjunct to autopsy in detecting occult fractures of the limbs. We recommend that PMSS be performed in suspected fatal NAI cases at least in children up to 24 months of age.

Prevalence of inflicted and neglectful femur shaft fractures in young children in national level I trauma centers

BACKGROUND

The prevalence of inflicted femur fractures in young children varies (1.5-35.2%), but these data are based on small retrospective studies with high heterogeneity. Age and mobility of the child seem to be indicators of inflicted trauma.

OBJECTIVE

This study describes other factors associated with inflicted and neglectful trauma that can be used to distinguish inflicted and neglectful from accidental femur fractures.

MATERIALS AND METHODS

This retrospective study included children (0-6 years) who presented with an isolated femur fracture at 1 of the 11 level I trauma centers in the Netherlands between January 2010 and January 2016. Outcomes were classified based on the conclusions of the Child Abuse and Neglect teams or the court. Cases in which conclusions were unavailable and there was no clear accidental cause were reviewed by an expert panel.

RESULTS

The study included 328 children; 295 (89.9%) cases were classified as accidental trauma. Inflicted trauma was found in 14 (4.3%), while 19 (5.8%) were cases of neglect. Indicators of inflicted trauma were age 0-5 months (29%, positive likelihood ratio [LR +] 8.35), 6-12 months (18%, LR + 5.98) and 18-23 months (14%, LR + 3.74). Indicators of neglect were age 6-11 months (18%, LR + 4.41) and age 18-23 months (8%, LR + 1.65). There was no difference in fracture morphology among groups.

CONCLUSION

It is unlikely that an isolated femur fracture in ambulatory children age > 24 months is caused by inflicted trauma/neglect. Caution is advised in children younger than 24 months because that age is the main factor associated with inflicted trauma/neglect and inflicted femur fractures.

Risperidone versus aripiprazole fracture risk in children and adolescents with autism spectrum disorders

Risperidone and aripiprazole, commonly used antipsychotics in children with autism spectrum disorder (ASD), have previously been associated with elevated fracture risk in other populations. The aim of this study was to evaluate and compare the risk of fracture among children with ASD using risperidone or aripiprazole. This was a retrospective, propensity-score matched cohort study, set between January 2013 and December 2018. We used the MarketScan Medicaid insurance data, which covers multiple states of the United States. We included ASD children aged 2-18 years, who were new users of aripiprazole or risperidone and with no prior history of antipsychotic use or fractures. The main exposure was the continued use of aripiprazole or risperidone. The incidence rates of any fracture during follow-up were evaluated, and the risk between aripiprazole and risperidone was compared via Cox-proportional hazard models. Results were stratified by age, sex, duration of exposure and fracture site. In total, 3312 patients (78% male; mean [SD] age 11.0 [3.7] years) were identified for each cohort. Over the full duration of follow-up, fracture incidence rates per 1000 patient-years were 23.2 for risperidone and 38.4 for aripiprazole (hazard ratio and 95% confidence interval: 0.60 [0.44-0.83]). Risks were similar between cohorts throughout the first 180 days on treatment, but significantly higher in the aripiprazole group thereafter. Extremity fractures drove most of the increased risk, with the biggest differences in lower leg and ankle fractures. Differences widened for children aged 10 years or younger (HR [95% CI]: 0.47 [0.30-0.74]). In conclusion, compared to aripiprazole, risperidone was associated with 40% lower risk of fracture. Further analysis on the mechanism and long-term bone health of antipsychotic-treated children with ASD is warranted. LAY SUMMARY: We compared the risk of bone fractures among 6624 children with autism spectrum disorder (ASD), half of whom used risperidone and half of whom used aripiprazole. Taking other factors into account, risks were similar between the two groups throughout the first 180 days on treatment, but significantly higher in the aripiprazole group thereafter. The biggest differences were in lower leg and ankle fractures. Overall, compared with aripiprazole, risperidone was associated with 40% lower risk of fracture.

CORRELATION BETWEEN FRACTURES AND ABUSE IN CHILDREN: A RETROSPECTIVE ANALYSIS

Objective:

The aim of this work is to provide evidence for the relationship between suspicion and diagnosis of cases of child abuse and fractures, since, in national literature, studies are still scarce on the subject.

Methods:

Retrospective study involving electronic medical records of a public reference hospital, in a city of the state of São Paulo, in a 8-year period (2010 to 2018). Cases involving children up to 12 years of age were selected when notified as abuse and presenting fractures; data were statistically analyzed. Results: Among 83 cases of abuse, 19 patients (20.5%) had 23 different fractures. The victims were mainly boys (68.42%) with a mean age of 5 years old, who suffered physical aggression (79%). The majority had no identified aggressor (52%) and 21% were related to the mother. The fracture patterns found involved, mostly, skull fractures (43.48%) and diaphysary fractures (34.78%). Seven patients (30.43%) had other associated lesions and four patients died (21%).

Conclusion:

Despite the number of cases, it was possible to identify relevant characteristics and patterns. These data indicate that the diagnosis is underestimated and show small epidemiological differences compared with international literature. Level of Evidence II, Retrospective study.

Characteristics of Nonaccidental Fractures in Abused Children in Riyadh, Saudi Arabia

Background:

Child abuse is a major problem globally. Nonaccidental fractures are the second most common injury among physically abused children; however, there is a lack of studies describing the characteristics of nonaccidental fractures in Saudi Arabia.

Objectives:

The objective of this study was to determine the characteristics of nonaccidental fractures among abused children in Riyadh, Saudi Arabia, using radiography.

Materials and Methods:

This retrospective study analyzed the data and radiographs of all nonaccidental fracture cases in children (aged ≤14 years) registered in the National Family Safety Program Registry at King Abdulaziz Medical City, Riyadh, between 2009 and 2015.

Results:

A total of 1512 cases of child abuse were found in the National Family Safety Program Registry database from Riyadh city. From these, 103 fractures were identified; however, radiographs were available for only 70 fractures from 56 children. Of these, 33 (59%) were boys, and 25 (45%) were aged 1–5 years. In terms of the type of abuse, neglect was more common than physical abuse (52% vs. 45%). History of injury was identified in 75% (42) of the cases, of which fall accounted for about 55% (23). Nearly 79% of children presented with a single bone fracture, while 21% had multiple bone fractures. The most common sites of fractures were skull (40%), upper limbs (31%) and lower limbs (29%). The most common fracture pattern was transverse fractures (48%), and it was mainly diagnosed in skull fractures (51%).

Conclusions:

This study found that in Riyadh, Saudi Arabia, neglect is the most common cause of nonaccidental fractures, abusive head trauma is the most commonly associated injury and transverse fracture is the primary pattern of fracture in abused children. Notably, as most children experienced a single-bone fracture, the authors recommend clinicians to lower their threshold of considering abuse even in cases with an isolated fracture.