Post-mortem diagnosis and age estimation of infants' fractures

Abstract

Detection and dating of infants' fractures plays an important role in the diagnosis of the battered child syndrome. Under this aspect three cases of infants with multiple fractures of different ages due to child abuse were evaluated post-mortem. Radiological findings were compared with the autopsy results, followed by contact radiography and histopathological assessment. Out of a total of 44 osseous lesions, 27 fractures were diagnosed by post-mortem skeletal survey, additionally 5 recent rib fractures were suspected, 4 of which were confirmed histologically and all were located paravertebrally. The fractures not detected radiologically were mostly recent rib fractures diagnosed or suspected at autopsy or by contact radiography and confirmed histologically. The histological investigation allowed a more precise dating of the fractures, particularly with reference to the early stages of fracture healing. Microscopic signs of fracture healing processes, such as periosteal thickening, osteoid production and calcification of soft callus tissue, can be detected earlier and quantified more accurately. In advanced stages of healing the osseous apposition rate can be measured semiquantitatively up to a certain extent. A scheme involving a careful external investigation, skeletal survey, autopsy, contact radiography and histology has been proven useful for diagnosing and dating infants' fractures.

Histological ageing of fractures in infants: a practical algorithm for assessing infants suspected of accidental or non‐accidental injury

“…2,5 However, while radiology detects overt and unsuspected fractures in dead infants, many may be missed. [6][7][8][9] Significantly, it is fractures that most closely correlate with NAI (e.g. posterior rib and metaphyseal) that are commonly missed.…”

“…posterior rib and metaphyseal) that are commonly missed. [10][11][12] Further evidence of fracture can be obtained at autopsy, 9,13 but naked eye examination also misses key fractures.…”

“…It is accepted that post-mortem histological examination of infant bones can detect fractures not seen radiologically. 9,11,13,14 Optimising detection of fractures is key, as multiple fractures and fractures of certain bones/parts of bones (e.g. posterior ribs, limb bone metaphyses) carry a high correlation with NAI and have causational implications.…”

“…whole‐body computerised tomography (CT)] can be employed . However, while radiology detects overt and unsuspected fractures in dead infants, many may be missed . Significantly, it is fractures that most closely correlate with NAI (e.g.…”

“…It is accepted that post‐mortem histological examination of infant bones can detect fractures not seen radiologically . Optimising detection of fractures is key, as multiple fractures and fractures of certain bones/parts of bones (e.g.…”