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
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Am
PL, Richmond
A, Spevak not to be confused 1991b; 156:781-3.
MR. with
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
J Orthop
deficiency
abuse.
JC. The abused 1983; 146:377-81.
fractures. abuse. JW. type
of child
In:
Kleinman
Baltimore,
Pediatr child
: a
PK,
ed.
etc : Williams
&
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
child 1972; of
146 :369-75.
imperfecta.
P, Stower M, Barbor P. Patterns
non-accidental 1986; 293:100-2.
infants, the battered Tardieu. Radio/ogy
scintigraphy
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
of growth-plate cartilage into the metaphysis : a sign of fracture in abused infants. Am J Roentgeno/ 1991a;
the suspected
fractures
subdural
Chapman S. Radiological 1990; 83 :67-71.
VOL.
femur 3:583-6.
trauma.
SC, Adams
of 1988;
PK, Marks
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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from a of this
of child I 990;
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imaging
Marks
radiological
Akbarnia B, Torg JS, Kirkpatrick J, Sussman battered-child syndrome. J Bone Joint 1159-66.
Astley
Diagnostic
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Merten M, Grix imperfecta.
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Magid
DS, Greenspan A, Reinhart abuse from osteogenesis 154:1035-46.
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King J, Diefendorf
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osteo-
are not features ofmild osteogenesis they do occur in the severe forms, of brittle bones is unequivocally
present The
that
DL, (‘battered
Herndon
genesis imperfecta is less than three in a,million. Many of the reports of this type have come from one author (Paterson, McAllion and Shaw 1987) but the validity of his work has been questioned (Ablin et al 1990). In practice, provided that care is taken to survey the evidence
Value
KJ.
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KW, Brewer DK. Child and rib fractures. Pediatrics
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Feldman
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(Ablin
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ABUSE
Ellerstein NS, assessment
fractures usually occur in the diaphyses and are unlike the corner metaphyseal fractures of abuse, although metaphyseal fractures are sometimes found (Astley 1979).
Type
CHILD
Ebbin
wormian 1990).
BY
Br
Med RI.
J 1987;
Long-bone injuries from
in accidental study.
and
Br Med J