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Idea Transcript


FRACTURES HELEN

M.

From

CAUSED

L.

BY

CHILD

Liverpool

Caffey’s

paper

on

the long

bones

and

Ghildren’s

the

NHS

association

subdural

Trust,

Hey,

Lirerpool,

fractures

of

present

published

in

diaphyses

between

haematoma,

Alder

1946, was the first modern description of quences of child abuse, now often referred

the to

euphemism

there

‘non-accidental

been many radiological

al

1962;

Since

papers

logical

Griffiths

describing

features

then

skeletal literature

their

in

Moynihan and

Marks

and

and

accidentally

(Anderson

Stower

Loder

and

aspects

Bookout

of the

injury

1982;

and

will

Barbor

Beals

and

King

1991 ; Thomas

musculoskeletal

et

injuries

al

the

are

presenting

evaluated.

already

no different history

In the case

fractures

those

has

therefore

of an isolated

medical

important

the non-

is another

further

or bruising

of

evidence,

an

such

elsewhere

to be carefully

appropriate

of a long history

that

ofabuse (Beals Delay in seeking

feature

as a torn

on the body,

acciden-

fracture

1963;

care

absence

of the

sustained

to the possibility et al 1991).

and

it is the

healing,

from

should alert the clinician and Tufts 1983; Thomas

radio-

Tufts

tally;

they

look

the 1957;

Blackbourne

1986;

when

bone,

1986; Kleinman et al 1991), and articles contrasting patterns of fractures caused accidentally and

Worlock,

ARTICLE

England

have

Leonidas 1983; 1990; Kleinman

pathological

(Kleinman,

conseby the

injuries (Caffey

and

1972; Merten, Radkowski and Norris 1984; Chapman

Ellerstein

1990),

injury’.

reports of the and paediatric

et

INVITED

CARTY

the Royal

Kempe Silverman

ABUSE

in the

frenulum

needs

history

of the

lips

to be specifically

sought. If there is bruising of a limb that is to be covered by a plaster or splint, it should be photographed before treatment

begins.

1983;

1991).

I. Fractures considered specificity for child abuse

Table

et al 1988;

high

These

of non-accidental

Metaphyseal

be reviewed.

to have

a

fractures

Rib fractures Scapular

fractures

INCIDENCE The

fractures

infants

of child

three

under

1983).

Akbarnia

abuse

years

occur

old (Ebbin

et al (1974)

most

frequently

et al 1969;

reported

that

in

of all such

fractures

were

50%

old. rare

By contrast, in children

accidental under one

in children

of the outer

Vertebral

fractures

were

Finger

in

under

one

injuries

Fractures

or subluxations

in non-ambulant

Bilateral fractures Complex

fractures are comparatively year (Worlock et al 1986).

caused

by child

abuse

which

are

skull

fractures

low specificity

such

significance,

as diaphyseal are

given

lesions, in Table

which III.

Mid-clavicular Simple Single

increase

Unless

cance

FRCR,

of

Radiology,

Royal

Alder Hey, Eaton Road, Liverpool ©l993

British

Editorial

0301-620X/93/6682 J Bone Joint Surg

VOL.

Consultant

Radiologist

and

Clinical

Liverpool

Children’s

NHS

Trust,

of Radiology

Department

75-B,

No.

Society

ofBone

$2.00 [Br] 1993 ; 75-B

6. NOVEMBER

LI 2 2AP, UK.

1993

:849-57.

and Joint

Surgery

fractures

linear

skull

diaphyscal

Ill. Features of a diaphyseal

Association

FRCPI,

abuse

fractures fractures

they Table

L. Carty,

for child

widely

thought to have a high specificity are listed in Table I, and those which occur frequently but have a low specificity in Table II. Some features of fractures with a

Director

children

ages

of different

specificity

H. M.

clavicle

Table II. Fractures which are frequent but have a low

fractures

their

of the

year

SPECIFICITY

The

end

Herndon

children less than one year old and 78% in children under three. Kogutt, Swischuk and Fagan (1974) found that 55%

Fractures

with

with

features

Inappropriate

Failure Discovery

that increase fracture

another

a high

specificity

clinical

to seek

fracture

medical

of the fracture

the or other

significlinical

for abuse

history

attention in a healing

state

849

H. M. L. CARTY

850

FRACTURE

PATTERNS

Metaphyseal are known

fractures of the long to be specific for child

common

than

reported

that

diaphyseal the

four times that Bookout (1991) counted whereas 1 5% and more 1974),

has

54#{176}/s (Merten

1983),

infants.

are

the

King

and

The

femur, stated

that

and

spiral

force,

should

cause

Several

reviews

have

addressed

cance of conclusions

was

Loder fractures

and ac-

supracondylar

fractures,

under (Merten

the

(Kogutt

Fig. I

et al

begun

to walk

significance

can

not

under due

to

et al 1991).

24 children under fractures had been

also the

of one

(1982) two

humerus

in

of

; Thomas

et

A recent transverse fracture of the mid-shaft of the humerus with a periosteal reaction along the diaphysis, indicating a previous injury. There is also periosteal reaction around the radius and ulna. The child also had multiple rib fractures (see Fig. 10).

non-accidenchildren have and

Femoral

year

and

are

Tufts

reported with

their of

suggestive

accidentally,

(Beals of

signifi-

et al 1991).

age

Anderson the age abused.

of the

et al 1986

do occur but once

a

abuse.

of the

happen

abuse

imply

child

are strongly

is less (Thomas

occurring

issue

all fractures

fractures et al 1986),

they

which of

1 and 2), and With the exception

et al 1983 ; Worlock

their

than

and Bookout injured long

fractures,

the age of three

al 1991). Supracondylar tally (Fig. 2) (Worlock

fractures

(Kogutt et al et al 1986),

tibia

suspicion

fracture types (Figs can be summarised.

children

in 23% (Worlock

27% (Loder most frequently

humerus

twisting

Thomas

fractures

et al 1988).

It is often

often

et al (1983)

of diaphyseal

been reported et al 1988), 74%

et al

199l)ofabused

abuse

Merten

they less

for 28% of non-accidental long-bone injuries Kogutt et al (1974) found the incidence to be Worlock et al ( 1986) 1 1 %. Coexistence of two or

5#{216}O/ (King

1974;

fractures.

incidence

although are much

of metaphyseal fractures. found that metaphyseal

fractures

bones

bones, abuse,

that

femoral

more 1983;

19 of shaft

Radiographs of a child mately admitted snatching its arm. On presentation

inflamed radiograph blurring

and swollen (a) showed of

the

supracondylar bone.

Four was

is also

days

later obvious

(b)

2a

Fig.

the child

planes

and

a healing

periosteal

subluxation

ofthe

the and

ulnar the

had an

The first oedema,

with

tion was of two different

Fig.

father ultithe child by

elbow. soft-tissue

fracture

There more

fat

whose up

new ulna.

subluxation

periosteal

reac-

ages.

2b

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

FRACTURES

Statements changed He must

such

as “It

must

have

his nappy”, or “I found him have caught his leg in the

know how for fractured

occurred

types abuse

to snatch

and

I

CHILD

thought.

ABUSE

851

Depending

bleeding, subperiosteal

in his cot like this. bars”, or “I don’t

on

fracture new

the

repair bone

extent

may be formation,

of

subperiosteal

accompanied but this

is

by not

sustain femoral fractures including shaft from falls (Thomas et al 1991) to be carefully scrutinised in each that the injury was accidental.

of fracture of the long bones seen in cases result from the use of the limbs as handles

the child

from

where

it has been

Beyond the toddling age children history. They may sustain non-accidental spiral

when

BY

it happened” are not adequate explanations femora in normal children. Young children

starting to walk may spiral fractures ofthe but the history needs case before accepting Several of child

CAUSED

fractures twists

the

Metaphyseal

ofa

tibia

indirectly

ifan

lying. can

relate their oblique or

adult

hand

grabs

limb. lesions.

The

metaphyseal

fractures

of child

abuse are usually very close to the growth plate, accidental metaphyseal fractures which are usually junction of the diaphysis and metaphysis and are torus variety (Fig. 3). The metaphyseal fractures of

unlike at the of the abuse

occur through the most immature part ofthe metaphyseal bone (Kleinman et al 1986) and an ossified fragment or ring of metaphysis is avulsed with the physis and may appear

as a ‘bucket-handle’

and 5). radiographic physeal

the

The and

or ‘corner’

fracture projection. are

metaphysis

not

may These simply

(Kleinman

fracture

be visible fractures

avulsions

1990)

of the

as

(Figs

4

in only one are transmeta-

was

periphery

Fig. An accidental fracture is

of

originally

between

metaphyseal not

at

the diaphysis

the

3 fracture

‘corner’

and

the

in a toddler. The at the junction metaphysis. but

Figure 4 - There is a corner fracture of the medial femoral metaphysis and a buckethandle fracture of the distal tibia. The femoral fracture healed without periosteal reaction. Figure 5 - A bucket-handle metaphyseal fracture of the proximal tibia with tibial subluxation and a corner fracture ofthe medial femoral metaphysis.

Fig.

VOL.

75-B, No.

4

6, NOVEMBER

Fig.

1993

5

H. M. L. CARTY

852

invariable

(Kleinman

et al

sometimes

stated,

the

no new

bone

has

that formed.

thickening

of the

metaphysis periosteal considerable

(Kleinman haematoma distance

physis

(Fig.

It is not

cannot

Repair

cortex

7b),

1986).

lesion

may

or squaring

true,

as

be a fracture appear

if

simply

of the

edges

as a of the

et al 1986; Figs 6 and 7). The when present may extend a from the fracture along the dia-

producing

a

much

more

extensive

periosteal reaction than an accidental metaphyseal torus fracture. Periosteal new bone may cloak the whole bone and even suggest a metabolic bone disease or dysplasia (Fig. 8). This generally indicates repeated trauma as also do breaks The

in the outer significance

layer of the periosteal new of metaphyseal fractures

Fig. 6

bone. is that

they are often caused by a shaking injury which can also inflict serious brain damage. The author has seen several medical reports in which such fractures were misleadingly described as ‘trivial’. The metaphyseal injuries usually heal are

without

long-term

not

important,

because

of their

A variant

consequences,

but

they

must

and

in that

be regarded

sense

as sinister

associations. of metaphyseal

injury

which

known is shown by a radiographic immediate subphyseal region (Fig.

is not

translucency 9), similar

so well

in the to that

sometimes seen in chronic illness such as leukaemia, the lesions are symmetrical, and evidence of the underlying disorder. That cencies are true metaphyseal fractures has

leukaemia. In there is other these translubeen conclu-

sively

(Kleinman

al 1986,

shown

1991);

by histopathological

their

significance

studies

must

not be overlooked.

et

Healing femur

metaphyseal without

fracture local

of the distal

periosteal

reaction.

The

diaphyseal periosteal reactions around the femur, tibia and fibula are traumatic. There is also a healing metaphyseal fracture of the proximal tibia (same child as in Figs 1 and 10).

The

radiograph on admission (a) shows an fragment of the distal tibial metaThree-and-a-half weeks later (b) the radiograph shows the squared off lower end of the bone and gross subperiosteal haematoma

avulsed physis.

which

THE

is now

JOURNAL

ossified.

OF BONE

AND

JOINT

SURGERY

FRACTURES

CAUSED

BY

CHILD

ABUSE

853

Fig. There is a healed erally. The lucent represents a further

limb

and

give

rise

9

metaphyseal line in metaphyseal

the

corner fracture subphyseal fracture.

to a suspicion

latarea

of osteomyelitis,

bizarre appearance on the radiographs often the confusion (Fig. 8). Acute osteomyelitis however,

accompanied

Chronic

osteomyelitis

and

in the

corner

The humerus shows gross periosteal reaction of several different ages. There is also a fracture through the new bone medially. This child was at first thought to have since on presentation

isolated.

They

she

had

a hot,

arm.

can

occur

from

most

commonly

seen

without

indirectly

applied

damage it has

and

Starshak Periosteal

1983). new

variation

1990).

caused

months.

In child

fractures

by direct

lesions

are

and

usually

are more

likely

by

to occur

force.

There

are

some

normal

which may be mistaken most common are small growth

plate,

which

metaphyseal

variations

for evidence of abuse. The two beaks or spurs adjacent to the may

look

like

corner

fractures

(Kleinman et al 1991). These spurs, however, are in continuity with normal bone and with the cortex. Metaphyseal fractures, even when recent, are frequently undetectable clinically by experienced clinicians. They do not apparently cause pain, except when they are severe

only need

or accompanied

evidence that for the skeletal Repeated

teal

bleeding

VOL.

75-B,

No.

by epiphyseal

they exist survey.

or severe may

6, NOVEMBER

injury

present

The

hence

with

subperios-

clinically

1993

displacement.

is radiological, extensive as a warm

the

swollen

changes

not

practice

it is seldom,

reaction

to fracture

in child

repair

Caffey

in the shaft

metaphysis,

but

(1946)

from shown

at

if

abuse

may

is

also

postulated

rough that

the

be that

gripping of the the lesions can

result from shaking alone, when acceleration and deceleration forces are applied to the unsupported limbs (Kleinman l987a; Chapman 1990). Areas of increased radionucleide uptake may be seen at sites of subperiosteal haemorrhage even when the radiographs are normal (Sty

a normal

and isolated

the

episode. Periosteal

occurred now been

on the radiograph.

causes

and in current

due

shaking or (Kleinman

Symmetrical

of

a fracture.

acceleration and deceleration forces during forceful pulling or twisting of an infant’s limb shaking

part

as in abuse,

periosteal limbs but

osteomyelitis

Metaphyseal fractures most commonly affect the femur and proximal humerus (Kleinman 1990). may be bilateral and symmetrical but they may also

tibia, They be

upper

central

ever, the presenting Periosteal new bone.

Fig. 8

swollen

by any changes

usually

the

adding to is not,

often

extends

injuries rare.

may Fracture

formation

abuse,

is sometimes

aged

however,

to the metaphysis

form the new bone to the diaphysis and aspect of the shaft involved bone is the the humerus and the Epiphyseal

bone

in infants

from

the periosteal while

injuries.

True

Salter-Harris

occur

from

child

separation

seldom

reaction

is always smooth, lamellar, confined usually most obvious on the medial of the bone. The most commonly femur, but this may also be seen in tibia.

of the

demonstrable. Rib fractures. The incidence abuse has been variously (Kleinman l987b). They are being

as

to six

in the physiological

abuse

seen

epiphyseal

but

epiphyses

tions are sometimes seen and may ultrasonography before they become

abuse,

seen

six weeks

are and

disloca-

be detected radiographically

of rib fractures recorded as 5% virtually diagnostic

as an accidental

plate

relatively

injury

by

in child to 27% of child even

in

H. M. L. CARTY

854

infants

who

have

been

occur

involved

in severe

in road-traffic

They

may

fecta, disease

and are seen, although rarely, and in premature infants. The

by Feldman and Brewer used in cardiopulmonary rib fractures. practice the

In author

caused

by cardiac

from

overenthusiastic

even

one

massage

broken

multiple

from when

a squeezing the infant

head

oscillates,

move

about

is therefore child

the

radiological a rib fracture

seen

only

one

The

highly

fracture

discovery

of

significant.

fracture

et

may

a whiplash

movement

be in any

transverse

and

costovertebral ligaments the head or neck. The detected radiographically

; the

man

et al

1988).

part

may

and

also result punching

forcibly

fractures

evidence

but

the

depends applied. of cortical

involving

the result may

palpable in thin infants. Recent rib fractures

radiographs

because

obliquity

ofthe when

fracture

they

are

of

relative

healing,

Fractures

which

were

may

invisible

when

they

may

be

overlooked

on

structures

and beam. necks

rib

be difficult to radiograph (Fig.

recent

(Fig.

become apparent when they are healing, therefore to repeat the chest film after

between

ribs

alert

should

sides the

and between

examiner

to

upper

see, 1 1).

12),

and it a week

and lower

the

possibility

of

show

posterior

rib

fractures.

Radionucleide

imaging

fractures as areas of increased may be visible on these scans

can

bone lesion

resorption (Magid

both

axillae

are

and

in the

of different

ages.

necks

of several

Intubation

was

ribs

because

injury.

uptake and more fractures than on radiographs. The

and and

can then be mistaken Glass 1990). Rib

fractures,

under

are

fractures.

A buckle

junction occurs

of a vertebral and dislocations, or lateral

DATING

OF

for some fractures,

commonly

fracture

of

other like

seen

and Glass

in

1990).

at the diaphyseal-

is another manifestation at the end ofa shaking

an impaction force when down on his leg on a hard thumping the child down fracture fractures

most

one year old (Magid

metaphyseal and probably

offlexion

to ten days in suspected cases. Abundant callus may develop around posterior fractures, but a common appearance is a widening of the neck of the rib due to apposition of new bone subperiosteally. Asymmetry of

the rib necks

head

Impaction

of the

when

in

fractures

associated

children is

to the X-ray

fractures

the vertebral column in an underpenetrated

may only is advisable

easily

ofthe

The

metaphyseal

accom-

fractures

overlapping

plane

are

even

fractures

symmetry of the lesions may cause them to be overlooked by those not familiar with interpreting paediatric radionucleide bone scans. A rib fracture may occasionally resemble a lytic defect when it is seen at the phase

anterior

are seldom

of healing

are

bilaterally.

10

at

of ribs may rib fractures

of trauma,

callus

There

readily (Klein-

and

degree

of fractures

of a number and anterior

Rib

Fig.

the

mechanically

lateral

to the

A row

away.

by external

close to especially

fail

in

from direct trauma, such as kicking, stamping, or contact with a hard edge when the infant

recent,

Even

tension

their incidence of the forces

is related

aspects Lateral

thrown

panied

ribs

of the

bleeding.

necks and lateral in a flail chest.

produces

also occur; and direction

of callus

disruption

1990).

the anteroposterior levers the rib over

neck fractures are most or with radionucleides

Fractures

parts of the ribs on the magnitude amount

(Kleinman

al (1992) state that applied during gripping processes

are

even the forces do not result in

injury to the chest (Kleinman 1990) is held by the thorax and shaken. The the thorax is compressed, and the limbs

with

Kleinman compression

The

has

bone paper

rib, but is more frequent in the posterior or the portions ofthe bone. The fractures are frequently and bilateral (Fig. 10); they commonly result

axillary

the

that

of paediatric encountered

and

imper-

in metabolic often quoted

physiotherapy. rib

accidents.

of osteogenesis

(1984) stated resuscitation

18 years has never

In an abused of the

forms

of abuse episode from

the child is forcibly surface. In a similar on its buttocks may

thumped fashion, result in

body (Kleinman l987c). Spinal however, are usually the result

flexion

injuries

(Kleinman

l987c).

FRACTURES

Precise dating of fractures is impossible; one can only define a time band in which it is likely that the fracture occurred. The longer from the time of the injury, the more imprecise is the estimate. In general, the greater

the severity

of the injury,

but in abused injury. If the

children second

the first has healed but repetitive disproportionate

the longer

repair may injury occurs

it is usually

injuries early bleeding,

is the repair be altered sufficiently

evident

process,

by repeated long after

radiographically,

in the repair and unusually

process florid

lead signs

repair. In spite

unanimity

ofthese

about

problems,

the approximate

THE

JOURNAL

there

is often

a surprising

age of a fracture

OF BONE

AND

JOINT

when

SURGERY

to of

FRACTURES

CAUSED

BY

CHILD

ABUSE

855

The chest

radiograph

(a) of a child

admitted

with a pulmonary rib fractures in Fig.

infection showed healing the left axilla. The film is underpenetrated and the detail ofthe rib necks is obscured. A further film seven days later (b)

Ila

showed several healing posterior rib fractures. Those on the right at 5 and 6 are, in retrospect, visible

Fig.

paediatric

radiologists

though

their

review

methods

are

films

of the

radiographs.

Table

agreed

scheme

for dating

fractures

it is not

personal

applicable

to

communication

It must

fractures

heal reaction.

evidence

but

an incorrect departments all children

No.

then

6. NOVEMBER

been now under

1993

first

and

the

Cohen

some

Table IV.

Dating offractures Diagnostic imaging of Wilkins, 1987:112) In :

(adapted from O’Connor JF, Cohen J. chi/d abuse. Baltimore : Williams and

but

(Duncan,

2 to 10 days

4 to 10 days

4 to 21 days

10 to 14 days

10 to 21 days

14 to 21 days

Softcallus

lOto2l

14to21

Hard

14 to 90 days

Soft-tissue

Early

resolution

periosteal

Loss offracture

detectable

new

bone

line

definition

callus

Remodelling

radiological

and

diagnosis

care

The

significance

discussed have two

need

must

an

hardly

be

be taken

to

of isolated

established old

admitted

days

3 mths

days

21 to 42 days

to 2 yrs

clinical

in this review.

years

Peak

Time

1987).

metaphyseal

radiologically

great

film.

a generally

injuries

that

with

diagnosis.

has already

whereby

75-B,

finger

a differential

even

accident

VOL.

any

offers

on

of the long bones

again

present

ofabuse,

fractures

IV

al-

depend

DIAGNOSIS who

considered,

independently, and

; O’Connor

without

DIFFERENTIAL In children

or

be emphasised

periosteal

avoid

rib

the

Ilb

subjective

quality

on

Most policy with

an

isolated

before

fracture

discharge

inadvertently

are

discharged

Physiological variations,

reviewed

to ensure

both

that to face

periostitis of

which

by

are

not

injury.

normal cause

paediatrician

at risk

further

and can

a

children

metaphyseal

confusion,

have

H. M. L. CARTY

856

A six-week-old healing

infant

fractures

was

of the

Table V. Classification Classification

Type

(+

admitted

necks

because

of the

left

of vomiting

7, 8 and

ofosteogenesis

9 ribs

imperfecta

(a). and

(after

Ablin

Clinical

radiologicalsubtypes)

The

chest

of the

radiograph

axillary

ends

was

of the

normal.

6 and

Ten

days

later

a further

radiograph

(b) showed

7 ribs.

et al 1990)

features

Sclerae

Inheritance

Blue

Autosomal

Blue

Autosomal dominant new mutation or

I

Subtype Subtype

A : normal teeth B : dentinogenesis

Mild to moderately severe osseous Normal or near-normal stature

imperfecta

Presenile

hearing

fragility

loss or impairment

dominant

(or family

history)

Most Type II Subtype

Subtype

A : broad, broad

B : broad.

crumpled, ribs with

crumpled.

discontinuous

Subtype

Type

long bones continuous beading

long

C : thin, fractured, long thin, beaded ribs

Intrauterine

growth

Moderate

A : normal

teeth

B : dentinogenesis

imperfecta

to severe

been

discussed.

Radiologists

surgeons

must

be familiar

with

these

radiological

features

lead to misdiagnosis. diagnosis has been

imperfecta. biochemical

are so typical Copper thoroughly

and

severe oflong

less frequent

orthopaedic an incorrect

during a difficult section. Such

Rickets testing

that

deficiency discussed

Normal

fragility

of long

bones

and

spine

blue

they

but

than

bone

not

as a differential (Carty 1988;

fragility and spine

in type

in

Autosomal

dominant

new

mutation

autosomal (rare)

normal

tween

recessive

Autosomal

dominant

I

child

imperfecta.

abuse

and

Ablin

et al (1990)

reviewed

genesis

-

or

Shaw 1988), but deficiency of sufficient severity to lesions that might be confused with child abuse rare (Shaw 1988). The major differential diagnosis, therefore,

and

and scurvy and their

should

osseous bones

or pale

or grey

Normal

to moderately deformity

identical to those caused by abuse of the fractures should avoid confusion. differential diagnoses are metabolic by

osseous

Mild

to avoid

diagnosis of abuse. Metaphyseal fractures may occur breech delivery or during caesarean

deformity

infancy becoming

Variable

already

disease and osteogenesis are easily eliminated

recessive

retardation

Short stature and severe growth retardation Deafness less frequent than type I

Deafness

fractures are careful dating The main

autosomal (rare)

-

bones

Progressive

Subtype

period

of ribs

III

Type IV Subtype

type

Lethal in fetal or perinatal Very severe osseous fragility

bones

or no beading

common

the

one

evidence.

imperfecta

now

of the

have The

used

forms

is be-

of osteogenesis

detailed

the problem

classification

is given

to lead is very

of osteo-

in Table

V. Types

II and III should not cause diagnostic difficulty as the bone disease is usually severe. In the mild forms of type I accidental fractures do not usually occur before the child

starts frequent

to walk under

while one THE

those year.

due

to child

In the more

JOURNAL

OF

BONE

severe AND

abuse forms JOINT

are more of type SURGERY

FRACTURES

I osteogenesis (Ablin

imperfecta

et al 1990)

and

distinctly

and

the

blue

there

is obvious

children

have

sclerae

(Ablin

et

CAUSED

osteoporosis bones

al

Their

IV is a rare

and

sporadic

form;

only

have

been

cases

Taitz (1987) estimated that age, with no family history, the

chance

that

a few documented reported

are

related

IV

Gnthths

critically

normal

in

1990),

and

infants

diagnostic

remembering

up

to four

confusion

seal and rib fractures imperfecta, although when other evidence (Astley

fracture

are not features

genesis

months

should

blue old

sclerae (Ablin

not occur.

are et

al

1979).

differential imperfecta

Subdural

haematoma

ofosteogenesis

and

typical

bone

changes

of osteogenesis

Overdiagnosis ofchild diagnosis of osteogenesis life

abuse

Osteogenesis

at risk.

uncommon

disease;

child

abuse,

sadly,

is an

in any party

form related

have been directly

Kleinman

A. Differentiation

Am

Anderson WA. Emerg Med

The significance

of femoral

J Roentgeno/

S. Manifestations Surg [Am] 1974;

fractures

in children.

of the 56-A: Ann

Kleinman

R. Metaphyseal

fractures

in osteogenesis

Br J Radio/

imperfecta.

Beals RK, Tufts

E. Fractured 1983;

JPediatrOrthop

Caffey

J. Multiple

chronic Caffey

Carty

in infancy

:

the role of child abuse.

in the long bones of infants hematoma. Am J Roentgeno/ 1946;

J. Some traumatic lesions in growing bones other and dislocations: clinical and radiological features. 1957; 30:225-38. H. Brittle

or battered.

75-B.

No. 6. NOVEMBER

Arch aspects

1993

Dis Child

1988;

of non-accidental

suffering 56:163-73.

from

than

fractures Br J Radio!

63:350-2. injury.

considerations. Baltimore,

In : Kleinman

Baltimore,

In : Kleinman etc : Williams

PK, Williams

etc:

In : Kleinman etc : Williams

ed. &

Diagnostic Wilkins,

PK, ed. Diagnostic imaging & Wilkins, 1987c :91-102.

in infant

Am

abuse.

B. The

J Roentgenol

metaphyseal lesion in Am J Roentgeno/

study.

VI, Blackbourne

posterior rib 150 :635-8.

fractures

SC Jr, Spevak

MR,

Kleinman

BD. Factors

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Belanger

Karellas

PK, Belanger PL, seal radiologic variants abuse. Am J Roentgenol

affecting

infants.

Am

PL, Richmond

A, Spevak not to be confused 1991b; 156:781-3.

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Normal findings

metaphyof infant

PK, Marks SC, Spevak MR, Richmond JM. Fractures rib head in abused infants. Radiology 1992; 185 :1 19-23.

MS, Swischuk

Kogutt

LE, Fagan CJ. Patterns

of uncommon fractures in the Roentgeno/ 1974; 121 :143-9.

RT, lookout Trauma

C. Fracture

DF,

Radkowski

MA,

reappraisal.

Shaw JC. Copper

syndrome.

children.

Am

J

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deficiency

abuse.

JC. The abused 1983; 146:377-81.

fractures. abuse. JW. type

of child

In:

Kleinman

Baltimore,

Pediatr child

: a

PK,

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Clinical and radiological features IVA. Acta Paediatr Scand 1987;

and non-accidental

injury. Arch Dis Child

63 :448-55.

Silverman FN. Unrecognized syndrome and the syndrome 104:337-53. Starshak IS.

as a sign

Leonidas

Paterson CR, McAllion SJ, Shaw of osteogenesis imperfecta 76:548-52.

Taitz

child

in battered

Radio/ogy

O’Connor JF, Cohen J. Dating Diagnostic imaging of chi/d Wilkins, 1987:103-13.

Sty JR,

of injury and significance

battered

patterns

of the

1991 ; 5:428-33.

N, Glass T. A ‘hole in a rib’ Radio! 1990; 20:334-6.

1988;

J

JM.

Kleinman

RJ.

Child

The

role

abused abuse

of bone

child. and

trauma in ofAmbroise

osteogenesis

injury

in children

1983;

in the evaluation

Markowitz accidental

of fractures

: a comparative

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146 :369-75.

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P, Stower M, Barbor P. Patterns

non-accidental 1986; 293:100-2.

infants, the battered Tardieu. Radio/ogy

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Radiology

295:1082-3. Thomas SA, Rosenfield NS, Leventhal JM, fractures in young children : distinguishing child abuse. Pediatrics 1991 ; 88:471-6.

Worlock J R Soc Med

The

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Chapman S. Radiological 1990; 83 :67-71.

VOL.

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SC, Adams

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Extension healing 156:775-9.

I982 ; I I : 174-7.

1979; 52:441-3.

Orthop

W, Silver HK. 1962 ; 181 :17-24.

in childabuse.

SC, Blackbourne

PK, Marks

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present The

that

DL, (‘battered

Herndon

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Value

KJ.

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KW, Brewer DK. Child and rib fractures. Pediatrics

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