Evaluating Children With Fractures for Child Physical Abuse

Abstract

Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures. Pediatrics 2014;133:e477-e489 INTRODUCTIONFractures are the second most common injury caused by child physical abuse; bruises are the most common injury. 1 Failure to identify an injury caused by child abuse and to intervene appropriately may place a child at risk for further abuse, with potentially permanent consequences for the child. 2-4 Physical abuse may not be considered in the physician' s differential diagnosis of childhood injury because the caregiver may have intentionally altered the history to conceal the abuse. 5 As a result, when fractures are initially evaluated, a diagnosis of child abuse may be missed. 3 In children younger than 3 years, as many as 20% of fractures caused by abuse may be misdiagnosed initially as noninflicted or as attributable to other causes. 3 In addition, fractures may be missed because radiography is performed before changes are obvious or the radiographic images are misread or misinterpreted. 2 However, incorrectly diagnosing physical abuse in a child with noninflicted fractures has serious consequences for the child and family. To identify child abuse as the cause of fractures, the physician must take into consideration the history, the age of the child, the location and type of fracture, the mechanism that causes the particular type of fracture, and the presence of other injuries while also considering other possible causes. DIFFERENTIAL DIAGNOSIS OF FRACTURES Trauma: Child Abuse Versus Noninflicted InjuriesFractures are a common childhood injury and account for between 8% and 12% of all pediatric injuries. [6][7][8] In infants and toddlers, physical FROM THE AMERICAN ACADEMY OF PEDIATRICSGuidance for the Clinician in Rendering Pediatric Care by guest on May 11, 2018 http://pediatrics.aappublications.org/ Downloaded from abuse is the cause of 12% to 20% of fractures. 9 Although unintentional fractures are much more common than fractures caused by child abuse, the physician needs to remain aware of the possibility of inflicted injury. Although some fracture types are highly suggestive of physical abuse, no pattern can exclude child abuse. 10,11 Specifically, it is important to recognize that any fracture, even fractures that are commonly noninflicted injuries, can be caused by child abuse. Certain details that can help the physician determine whether a fracture was caused by abuse rather than unintentional injury include the hist...

The Evaluation of Suspected Child Physical Abuse

“…[104][105][106][107] Additional discussion related to the differential diagnosis of fractures and fracture evaluation in suspected child abuse can be found in the recently published AAP clinical report. 108 …”

Critical Elements in the Medical Evaluation of Suspected Child Physical Abuse

“…Over the past decade, the American Academy of Pediatrics has published a series of practice recommendations for the medical evaluation of suspected child physical abuse based on expert opinion and literature review. [3][4][5][6][7] The strength of evidence supporting these recommendations remains limited, however, and may contribute to variability in diagnostic evaluations.…”

“…Previously published recommendations reflect this uncertainty by providing a broad catalog of historical, laboratory, and radiographic data to be considered by physicians in the evaluation of suspected abuse. [2][3][4][5][6][7] Without unbiased cohort data to specify critical elements of this diagnostic evaluation, a "pick-and-choose" application of these recommendations may lead to practice variability, contributing to both over-and underevaluation of children with injuries concerning for abuse. [9][10][11][12] In this setting of uncertainty, consensus of expert opinion can provide credible guidance for physicians involved in the medical evaluation of suspected abuse.…”

Prenatal onset of sporadic form of infantile cortical hyperostosis

“…17 Battery baby syndrome is differentiated from Caffey's disease by the presence of multiple fractures at different stages of healing, delay in obtaining medical treatment, and the presence of other organ injuries. 18 Osteogenesis imperfecta (OI), a genetic disorder of collagen synthesis, is characterized by bones that break easily from little or no apparent cause. Radiographic findings include osteoporosis of both the axial and appendicular skeleton, over tubulation (gracile) of long bones, and healing fractures.…”