More than half the victims of child abuse have fractures. The orthopedic surgeon will often be the first person to identify a potentially abused child.
The safest pathway for the child and the clinician is to follow the local child-abuse protocol in all suspicious cases.
Any child is a potential victim of nonaccidental injury.
Household income does not relate to risk.
Aspects of the medical history can also constitute pointers to potential child abuse.
The context of the alleged event leading to injury may also indicate risk.
See: Kemp, A M, Dunstan F, Harrison S, et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ 2008 Oct 2;(337): a1518. This article concluded:
“When infants and toddlers present with a fracture in the absence of a confirmed cause, physical abuse should be considered as a potential cause. No fracture, on its own, can distinguish an abusive from a non-abusive cause. During the assessment of individual fractures, the site, fracture type, and developmental stage of the child can help to determine the likelihood of abuse.
Because children with certain genetic syndromes can bruise more easily, if the physical examination suggests a syndrome (eg, laxity of skin and hypermobile joints as seen in Ehlers-Danlos syndrome), a specialized genetic evaluation is indicated.
The most troublesome differential diagnosis is between nonaccidental injuries and osteogenesis imperfecta (OI).
OI is protean in its manifestations and in 1979, Sillence classified five types, based on clinical and radiological features. This classification has since been modified in the light of further genetic data.
The classical blue sclera are not always present and the onset of fractures can be delayed. It is a difficult diagnosis to substantiate and is the province of specialist pediatricians and geneticists.
If a child presents with unexplained fractures and none of the risk factors for nonaccidental injuries is present, then OI has to be considered by appropriate experts.
In 1995, Roger Smith of Oxford stated “The distinction between NAI and osteogenesis imperfecta is a small and untidy corner of pediatrics. Osteogenesis imperfecta is rare and few people have extensive experience of it; the views of those who have should be taken into account, irrespective of their specialty. Where legally necessary biochemical confirmation of osteogenesis imperfecta should be sought.” ( Smith R. Osteogenesis imperfecta, non-accidental injury, and temporary brittle bone disease. Arch Dis Child. 1995 Feb;72(2):169-176.)
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