Chapter 9: The Orthopedic Recognition of Child Maltreatment

Richard M. Schwend, Laurel C. Blakemore, Kristin A. Fickenscher

Chapter Outline

Introduction

Terminology

Child maltreatment is any act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.272 Child maltreatment includes all types of abuse and neglect that occur among children under the age of 18 years.221 The four common types of maltreatment include physical, sexual, and emotional abuse as well as child neglect.130 Maltreatment can be acute or chronic over a number of years, with worse outcomes when inflicted over a number of years with multiple events.137 Neglect is the most frequently encountered type of child maltreatment.79 Psychological maltreatment is increasingly recognized to be as harmful as other types of maltreatment.116 Recent terminology for a battered child, physical abuse, or child abuse include child maltreatment, nonaccidental injury (NAI), inflicted injury, or nonaccidental trauma (NAT).93 Child maltreatment occurs when a parent or caregiver is the perpetrator; whereas bullying involves maltreatment by another child.146 

Epidemiology

The National Child Abuse and Neglect Data System (NCANDS) was initiated in response to Public Law 93–247 to collect and analyze child abuse statistics.271 NCANDS documents that the epidemic of child abuse continues to worsen in the United States, with approximately 3.6 million reports (47.8 per 1,000 children) filed in federal fiscal year 2006 compared to 1.2 million in 1982.272 Approximately one-quarter of these children who received an investigation were confirmed to have been abused or neglected. This represents a victim rate of 12.1 per 1,000, totaling 905,000 US children in 2006.272 Approximately 60% of confirmed cases are neglect, 16% physical abuse, 10% sexual abuse, and 7% psychological abuse.221 Reports by professionals are more likely to be confirmed. Although children under the age of 4 years are at greatest risk for maltreatment, the victim rate is highest for infants, totaling 91,278 (23.2 per 1,000 population over the course of less than a year).53 Newborns in the first week of life may be at the highest risk, with a total of 29,881 reported cases, 70% of which were reported for neglect.221 One of every 1,000 abused children in the United States die.135 Three children die of abuse or neglect each day,274 with 50% to 80% having evidence of a prior injury. The World Health Organization estimates that 57,000 children worldwide die from maltreatment, while more than 1,500 die in the United States.166 However, mortality rates are commonly underestimated.69,114 Nineteen percent of maltreatment fatalities occur in infants; whereas, newborns in the first week of life have greatest risk of death.221 Abuse is second only to sudden infant death syndrome (SIDS) for mortality in infants 1 to 6 months of age and second only to accidental injury in children older than 1 year. The incidence of abuse is three times that of developmental dysplasia of the hip or clubfoot. Fortunately, there is some evidence that abusive fracture incidence may be decreasing over the past 24 years, possibly because of a general increase in recognition of child maltreatment and more preventive services available to families.174 
The estimated national cost of child abuse for the child welfare system is 14 billion dollars, law enforcement 24 million, and the court system 341 million.274 The long-term social costs of child abuse are substantial: One-third of the victims of child abuse grow up to be seriously dysfunctional, neglectful, or abusive parents; one-third are at high risk for eventually becoming abusive parents; and only one-third do not repeat the destructive patterns they were exposed to as children.206,252 Exposure to adverse childhood experiences has a high probability of both recent and lifetime depressive disorders.59 Direct and indirect total estimated national costs of child abuse, including special education for learning disorders of abused children, maternal mental and health care, legal costs of juvenile delinquency, lost productivity to society of abused and neglected children as unemployed adults, and later adult criminality of abused and neglected children in 2012 is 124 billion dollars.54 
The orthopedist becomes involved in the care of 30% to 50% of abused children.5 Early recognition by the orthopedist is critical because children returned to their homes after an unrecognized episode of child abuse have a 25% risk of serious reinjury and a 5% risk of death.230 Jenny and Isaac133 have noted a threefold increased mortality rate of children who have been listed on state abuse registry for all types of abuse. The mortality rate is highest for those who are physically abused, especially infants.133 

Overview

In 1946, Caffey45 described six infants with long-bone fractures, chronic subdural hematomas, and intraocular bleeding without a history of trauma to explain the injuries; however, he did not speculate about the etiology of the children's injuries. Although his work is cited as the first report in the English literature of child abuse, it was Ambroise Tardieu, the prolific French forensic physician, who during the mid-1800s described in great detail the condition of sexual abuse in children, as well as the battered child syndrome.168 In 1953, Silverman240 characterized the unique metaphyseal fractures found in abused children and clearly emphasized that these were because of NAT. Altman and Smith8 published the first series in the orthopedic literature of injuries caused by child abuse in 1960. General public awareness of child abuse increased with the 1962 publication of a report by Kempe et al.145 characterizing the problems as the battered child syndrome. In 1974, Caffey46 introduced the term “whiplash-shaken infant syndrome” to the literature to emphasize the etiology of subdural hematomas in infants caused by shaking episodes. In 1974, Congress acknowledged the national importance of the prevention of child abuse by the passage of the Child Abuse Prevention and Treatment Act.271 Because pediatric personnel and hospital-based child protection teams must be aware of reporting requirements for child maltreatment, there are published guidelines for the establishment and management of hospital-based child protection teams.193 

The Risk Factors for Child Abuse

The Home at Risk

In assessing where child abuse may occur, households in turmoil from marital separation, job loss, divorce, family death, housing difficulties, or financial difficulties are more likely to have abusive episodes.81 When one twin is abused, the second twin is at higher risk to be concurrently abused than a nontwin sibling or contact.180 One of the most important predictors of abuse is the presence of a nonrelated adult living in the household. Compared to single parent families, death caused by child abuse was noted to be 50 times higher in households that had unrelated adults; the perpetrator was the unrelated adult in 83.9% of these cases.231 Families with two unplanned births are 2.8 times more likely to have an episode of child abuse than families with no unplanned births.285 Stepparents, babysitters, boyfriends, relatives, and even larger siblings may be abusers.4,115,207,236 Young, unmarried mothers are more likely to have an infant death from intentional injury, with a peak incidence of 10.5 intentional deaths per 10,000 live births.237 In a study of 630 fractures in 194 abused children, the perpetrator was identified in 79% of cases.248 Sixty-eight percent of the perpetrators were male, and 45% of the time the biologic father was responsible. Abused infants were significantly younger (4.5 months of age) when a male had abused the child, than when a female was the abuser (10 months of age). The parents of battered children may themselves have been abused when they were children.100 High levels of parental stress and belief in corporal punishment are associated with child abuse.68 Parental substance abuse, whether alcohol or other drugs, makes child abuse more likely.111 The risk of physical abuse is fivefold more likely with maternal cocaine use.275 Violence in the home is not directed solely toward the child. In one study of families with substantiated child abuse, 30% of the mothers had also been abused.47 Although the youngest, poorest, most socially isolated, and economically frustrated caretakers are the most likely to act violently toward their children,280 any adult from any social or economic level may abuse a child.4 Day care may be an at-risk environment in situations when there is poor supervision of the child caregivers. However, in an analysis of 1,362 deaths in day care, home day care was a much higher risk than was a formal institutional day care because of less training and supervision of the adult caregivers and the absence of adult witnesses.281 Primary parental predictors of child abuse are listed in Table 9-1
 
Table 9-1
Parental Predictors of Child Abuse
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Table 9-1
Parental Predictors of Child Abuse
General
  •  
    Unrelated adult living in the homea
  •  
    Parent history of child abuse
  •  
    Divorce or separation of mother's parents
  •  
    Maternal history of being separated from mother, parental alcohol, or drug abuse
  •  
    Maternal history of depression
  •  
    Child attends a home day care
Mother
  •  
    Age less than 20 years
  •  
    Lower educational achievement
  •  
    History of sexual abuse
  •  
    Child guidance issues
  •  
    Absent father during childhood
  •  
    History of psychiatric illness
Father
  •  
    Age less than 20 years
  •  
    Lower educational achievement
  •  
    Child guidance issues
  •  
    History of psychiatric illness
 

Adapted from Sidebotham P, Golding J. The ALSPAC Study Team: Child maltreatment in the “Children of the Nineties”—a longitudinal study of parental risk factors. Child Abuse Negl. 2001; 25:1177–1200, with permission.

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The Child at Risk

Most reported cases of child abuse involve children younger than 3 years of age.96 In one report of abused children,30 78% of all fractures reported were in children younger than 3 years of age and 50% of all fractures occurred in children younger than 1 year of age. Infants younger than 1 year are especially at risk for infant homicide, the most severe form of child abuse.76,151 The problem may be more widespread than suspected. In one report,35 covert video recordings of adults attending their children who were hospitalized for suspicious illness documented 14 separate instances of caretaker attempts to cause upper airway obstruction. An infant may present to the emergency room dead or near dead after an apparent “life-threatening event.” In these cases, it is important to be open to all diagnostic possibilities and use a multidisciplinary team approach to the evaluation.201 Possible explanations for these events include SIDS, metabolic disease, cardiac disease, infection, as well as accidental or nonaccidental suffocation. Up to 11% of infants treated in the emergency room for apparent life-threatening events are later confirmed to be victims of child abuse.39 Firstborn children, premature infants, stepchildren, and disabled children are at a greater risk for child abuse, as are twins and children of multiple births.30 Benedict et al.,31 in a longitudinal study of 500 disabled children followed from birth to age 10 years, documented a 4.6% incidence of physical abuse. The most severely disabled children were less likely to be abused, whereas marginally functioning children were at greater risk, with parental frustration considered to be a factor. 

The Risk for Child Abuse that Occurs in a Medical Setting

Children who are repeatedly presented by parents for medical assessment of vague illness and have a history of multiple diagnostic or therapeutic procedures for unclear reasons are at risk for having a form of child abuse known as “child abuse that occurs in the medical setting.”251 This term has replaced the previously used “Munchausen Syndrome by Proxy,”193 named after Baron von Munchausen, an eighteenth-century mercenary whose exaggerated tales of adventure were viewed with great suspicion. In child abuse that occurs in a medical setting, children become the victims of this adult behavior when misguided parents fabricate a wide range of illnesses for their children, often subjecting them to needless diagnostic workups and treatment.193 Symptoms of the child's “illness” are based on an imaginary medical history given by the parent, with signs of the illness either simulated or induced by the parent. For example, a child may be brought into the emergency room by a parent with a complaint of vomiting. This complaint may either be a total fabrication by the parent or the parent may simulate the complaint by producing “vomitus” from some source as proof of illness. In one report, bloodstained material was presented by a caretaker as proof of a child's “gastrointestinal bleeding,” but DNA testing revealed that the source was actually from the caretaker.276 Conjunctivitis from a caustic agent placed on an infant by a caretaker has been reported.28 Children have been given clozapine and clonidine by caretakers to simulate illness.27 A parent has caused vomiting in a child by the administration of salt191 or ipecac. In other extreme cases, a rodenticide-induced coagulopathy was seen in a 2-year-old child,18 a deliberate self-induced preterm labor was caused by a parent,98 and another repeatedly gave insulin to a 1-year-old child.193 Over half of reported cases of child abuse in the medical setting involve induced symptoms, whereas 25% involve a combination of both simulation and induction of symptoms.39 In less severe cases, the parent's anxiety can cause them to obtain unnecessary and harmful or potentially harmful medical care, even though the parent believes that he or she is acting in the child's best interest. Physicians need to be vigilant so as not to be an unwary participant of this form of child maltreatment. 
The biologic mother is almost always the perpetrator of child abuse in the medical setting,227 but men can be responsible.192 Caretakers often have a medical background: 35% to 45% are nurses, 5% are medical office workers, 3% are social workers, and 1% are orderlies.227 The perpetrator of the child's illness denies the knowledge of its etiology; however, the acute signs and symptoms of the child's illness will resolve if the syndrome is recognized and the child is separated from the parent.227 Follow-up of families with this disorder is crucial. Failure to diagnose this condition places a child at risk for either serious long-term sequelae or death in approximately 9% of cases. 
The diagnosis of child abuse in the medical setting remains difficult. Health care workers must have a high degree of suspicion when children present with repetitive illness with no physiologic explanation. Physicians need to recognize that their perseverance in finding an explanation to a child's illness may contribute to the inflicted harm to the child. When possible, a pediatrician with experience in child abuse should become involved in the evaluation as well as the hospital or community-based multidisciplinary child protection team. A thorough review of all the medical care received by the child and communication among team members is necessary to establish the diagnosis and to recognize patterns of parental behavior that may harm the child. Covert video surveillance (CVS) of caretakers with their children may be a valuable means to substantiate or disprove this diagnosis. Hall et al.102 reported that CVS with audio surveillance allowed diagnosis in 56% of patients monitored and was supportive of the diagnosis in another 22% of children. The approach is expensive, is not covered by third-party payers, and so is infrequently used. Effective treatment generally involves assuring the safety of all children in the family and addressing ongoing dysfunctional family behaviors. 

The Risk for Sexual Abuse

Although the orthopedist usually considers child abuse in the context of fractures and other obvious injuries, an increasingly important situation to recognize is sexual abuse. It is estimated that 25% of abused or neglected children have been sexually abused.167 Physically abused children have a one in six chance of being sexually abused, whereas sexually abused children have a one in seven risk of being physically abused.117 Children living with nonbiologic parents or with caretakers who are substance abusers are most at risk. The child usually discloses sexual abuse under three types of circumstances: The child may have just experienced an argument with the abuser and may “accidentally” reveal the existence of the abusive relationship, the child is permanently separated from the abuser, or the abusive adult is shifting attention to a younger sibling.279 Up to 25% to 83% of children with a disability have been reported to be abused.257 

Obtaining the History

The history is critical in the diagnosis of child abuse, which is a team effort with the consulting pediatrician, social worker and other personnel from the hospital's child protective team, child protective services worker, law enforcement, and the appropriate consulting service. The orthopedic surgeon is involved if the child has an injury to the musculoskeletal system. The history is usually taken in the chaotic environment of a busy emergency room, so it is important to find a quiet area for the interview to be conducted calmly and with minimal distractions. The orthopedic surgeon should focus on the facts of the injury, including the child's ability to get into the injury scenario, details of when, where, and what happened, the child's position and action before the injury, position after the injury, how the child reacted, and how promptly the caregiver responded appropriately. Such detailed interview skills rarely are taught during residency training. In a survey of pediatric residents, 42% of them had 1 hour or less in training for detection of child abuse, and most orthopedic residents likely have even less.80 In a study comparing the documentation of physical abuse between 1980 and 1995 in a teaching hospital, very little improvement was noted.179 Little progress has been made in how frequently physicians inquire about basic historic information such as the timing of the injury and who were the witnesses.14 The type of hospital that an injured child visits also influences the likelihood that a diagnosis of abuse will be made.269,270 General hospitals were less likely to diagnose a case of abuse compared to children's hospitals. Use of a structured clinical form can increase the information collected to support the diagnosis of child abuse.24 Having received recent continuing medical education focused on child abuse was the most important factor for a physician to properly recognize and report child abuse.90 Precise documentation in child abuse is vital for reasons beyond medical care. Although most subpoenas for testimony by physicians in child abuse cases do not result in courtroom appearances,212 all documentation in child abuse cases may become evidence in courtroom proceedings. Thus, detailed records are helpful to all in courtroom testimony by physicians.105 The history needed to document child abuse is termed the investigative interview, is a team effort, and should be led by members of the child protective team and the police when potential child abuse is investigated. 

The Orthopedic Interview

When involved, the orthopedic surgeon performs a detailed musculoskeletal history and physical examination to characterize the features and mechanism of the obvious injury and to discover evidence of additional undocumented injuries. The interview documents the history (or the lack of history) of the presenting injury and attempts to uncover enough details about the child's life so that plausible scenarios can be evaluated that might explain the injury. The team should determine how the injured child lives, find out which family members, friends, or other caretakers have access to the child, and how likely it is that they might have contributed to the child's injuries. A detailed history of injury is obtained individually from each adult family member in a private setting. If the patient and siblings can communicate, they should be interviewed separately from the parents and other members of the family. The location where the injury occurred and which individuals were actually present are documented. The interviewer should follow a systematic review of symptoms: What happened, who was there, when the injury was recognized, and how long before medical treatment was sought. To avoid provoking emotions, any additional soft tissue or skeletal trauma discovered should be brought up at the end of the interview for explanation once the presentation injury has been thoroughly discussed. 
Delay in seeking medical care for an injured child is very suggestive of child abuse.81 An infant who has sustained abusive head trauma (AHT) typically will develop immediate neurologic change and will invariably show symptoms within a few hours.37 For a child with head trauma, a caregiver's story that there was a long period after the injury in which the child had no symptoms is suspicious. When central nervous injury in child abuse is significant or severe, it is immediately symptomatic; thus, the last caretaker who witnessed the reported injury or found the child immediately after the injury is highly suspected of being the perpetrator.23 Inconsistencies are not challenged during the interview. Leading questions are avoided in favor of open-end questions. Medical terms should be explained in plain English, with care taken to avoid medical jargon. More plausible explanations for the injury are not volunteered. Open prompts can enhance the interview.209 If the injury was observed, the caregiver should be able to give a detailed description of the injury mechanism that fits the energy of the fracture and the clinical picture.218,219 The crucial questions to be answered are not only whether the given history of trauma is sufficient to explain the severity of injury, but also what other possible scenarios could explain the injury if the volunteered explanation is not plausible. This requires obtaining a working knowledge of the child's environment, which team members can obtain by asking specific, detailed questions (Table 9-2). 
 
Table 9-2
Child Abuse: Investigative Interview
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Table 9-2
Child Abuse: Investigative Interview
Environmental Issues
Primary Caretakers
  •  
    Unsupervised
  •  
    Responsible for feeding, discipline, toilet training
  •  
    Easy or difficult child
Home Environment
  •  
    Place of residence
  •  
    Living conditions
  •  
    Adults employed or unemployed
  •  
    Sleeping arrangements
  •  
    Marital status of parents
  •  
    Boyfriend or girlfriend of single parent
  •  
    Substance abuse
Home Stress Level
  •  
    Recent job loss
  •  
    Marital problems (separation or divorce)
  •  
    Death in the family
  •  
    Housing problems
  •  
    Inadequate funds for food
Parental or Caregiver Responses and Attitudes
  •  
    Evasive, not readily responsive to questions
  •  
    Irritated by questioning
  •  
    Contradictory in responses
  •  
    Hostile and critical toward child
  •  
    Fearful of losing child or criminal prosecution, or both
  •  
    Unconcerned about child's injuries
  •  
    Disinterested in treatment and prognosis
  •  
    Intermittently unavailable for interview (without valid reason)
  •  
    Unwilling to give medical information
  •  
    Unwilling to give consent for tests
  •  
    Indifferent to child's suffering (seldom touches or looks at child)
 

Adapted from Akbarnia BA. The role of the orthopaedic surgeon in child abuse. In: Morrissy RP, ed. Lowell and Winter's Pediatric Orthopaedic. Philadelphia, PA: JB Lippincott; 1990; Green FC. Child abuse and neglect: A priority problem for the private physician. Pediatr Clin North Am. 1975; 22(2):329–339, with permission.

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When interviewing injured children, it is essential to be as gentle as possible, asking how they got hurt rather than who hurt them. Questions asked should be appropriate for the child's age. The child's account of what he or she was doing at the time of injury should be compared with the accounts of the adult witnesses. If possible, the siblings of the injured child should be interviewed because they are also at risk for child abuse. Nonvisual cues during the interview should be noted (Table 9-2). 
To make the diagnosis of child abuse, the orthopedic surgeon or child abuse team must determine if the history of trauma is adequate to explain the severity of injury.56 This should be based on the experience in the care of fractures with knowledge of their mechanisms of injury and special insight into the types of trauma most likely to cause significant injury. In addition, it is extremely important to have knowledge of the developmental abilities of a child when a caretaker states the child's injuries are self-inflicted.135 For example, if the parents explain that a 4-month-old infant's femoral fracture occurred in a fall while the infant was standing alone, this history is inconsistent with the child's developmental ability. 
Details given as the reason for the injury should be carefully considered. Although it is not unusual for a young child to sustain an accidental fall, it is unusual to sustain a serious injury from that fall alone. Infants fall from a bed or a raised surface during a diaper change fairly frequently. In a study of 536 normal infants,165 nearly 50% of them had fallen accidentally from an elevated surface, usually after the first 5 months of life, when the children were able to roll over and were more active. Significant injury in such falls is, however, extremely rare. Combining two studies of 782 children younger than 5 years of age who accidentally fell off an elevated surface, such as bed or sofa, reveals that injuries were limited to three clavicle fractures, six skull fractures, one humeral fracture, and one subdural hematoma.112,163 In another report, a much higher rate of fracture was seen in falls from furniture with 98% having fractures, mostly in the upper extremity, because of the child catapulting during play activity rather than sustaining a simple short-height fall.113 More severe injuries occur in falls from greater heights. Stairway falls usually result in low-energy injuries, but there is increased risk of injury if the child is being carried by the caregiver. In a report of 363 stairway injuries,145 10 were infants who were dropped by their caretakers and four of those sustained skull fractures. In patients 6 months to 1 year of age, 60% were using walkers at the time of the stairway injury. Only 4% of patients had extremity fractures and 1% had skull fractures. Reported short-height falls (<1.5 m) are rarely documented to cause death.55 A review of child mortality in infants and young children in California showed the following causes of death/1 million children/year: Prematurity 165, congenital malformation 316, neoplasms 33, respiratory 38, accidents 121, homicide 22, and short-height falls 0.48 (a total of six cases, all occurring in the home). Although short-height falls are a rare cause of death, there has been no reported case of shortfall death in an institution-type day care setting, where witnesses are typically present. A fatally injured child from a reported short-height fall at home must receive expert postmortem investigation for child abuse. 
Additional information about the child and the family may be obtained by a review of past medical records or by contacting the patient's primary physician and social workers who may have been involved with the family. The physician or social worker should be asked if there has been any previous pattern of injury, illness, ingestion of objects or medications, or noncompliance with health care recommendations; whether the family is receiving counseling or other support from any community groups; and whether the family has any previous involvement with child protective services or law enforcement.80 

Documentation Requirements

Careful documentation is critical. Chart notes may later be presented as evidence in court for either custodial hearings or criminal trial.179 Defending inaccurate or partial chart notes in court can be extremely embarrassing as well as placing the child at additional risk. Each account should be recorded in as much detail as possible, using quotation marks for exact quotes and specifying who is giving the history. Particularly with crucial answers, the exact question preceding the response should be documented. In a study of subsequent confessions, the initial history, although not consistently true, did reveal some elements of truth.88 In addition, the general emotional state of the individual providing the account, as well as the individual's reaction to emotionally charged questions should be documented to assist in later evaluation of the credibility of the account. If the family wishes to change their story after the initial account, no changes should be made to the earlier record, but an addendum should be placed detailing the new account. The completed record should include several specific items such as the timing and mechanism of the injury, who found the child, timing of events, family history of underlying conditions such as osteogenesis imperfecta (OI), radiographs, and documentation of protective services involvement. 

Physical Examination

After the initial musculoskeletal evaluation for acute fracture assessment, a detailed physical examination should follow, systematically evaluating from head to toes, to detect any signs of additional acute or chronic injury. Acute and subacute fractures may cause local tenderness and swelling, whereas chronic fractures may produce swelling from the presence of callus and clinical deformity from malunion. Radiographs are obtained to confirm clinically suspected fractures. A skeletal survey must be performed in children under 2 years of age when there is reasonable suspicion of abuse12: It should be considered an extension of the physical examination for this age group. A thorough examination should focus on the body areas commonly involved in child abuse including the skin, central nervous system (CNS), abdomen, and genitalia.207 Careful evaluation for signs of previous injury is useful because 50% of verified abuse cases show evidence of prior abuse.100 

Soft Tissue Injuries

In addition to examination of the soft tissue around the acute fracture site for swelling and bruising, the patient's entire body should be systematically evaluated to detect acute and chronic soft tissue trauma. Deliberate soft tissue injuries are present in 81% to 92% of abused patients,96,190,159 making them the most common abuse-related physical examination finding. The types of skin lesions commonly encountered include bruises, welts, abrasions, lacerations, scars, and burns. 
The number and location of bruises relate to the child's development. Seventeen percent of mobile infants, 53% of toddlers, and most school children have bruises.185 Young infants have a much lower prevalence of accidental bruising (seen in 1%) compared to mobile toddlers.185 Accidental bruises in babies are also typically noted over bony prominences.49 The toddler may have multiple accidental bruises over bony prominences such as the chin, brow, knees, and shins.4,230,255 Bruises on the back of the head, neck,4 arms, legs, buttocks, abdomen, cheeks, or genitalia may be suspicious for abuse, although accidental bruises can also occur in all these locations.8 Accidental bruising of the face is much less common and should be carefully evaluated.185 In the dentistry literature, in a series of 266 children suspected of being abused, Jessee and Rieger134 reported that bruises were the most common soft tissue injury, with the most common facial. In nonabused children, only 7% had accidental soft tissue injuries of the face and head, with the peak incidence of 17% seen in toddlers; whereas, soft tissue injuries were present on the lower extremities and buttocks in 31% of children and on the upper extremities in 9%.225 In a study of 1,467 patients seen for reasons other than trauma at a medical center over a 1-year period, 76.6% had at least one skin lesion of recent onset, 17% had at least five, 4% had at least 10, and fewer than 1% had more than 15 recent lesions.169 In children less than 9 months of age, skin lesions were uncommon and were concentrated on the head and face, whereas in children over 9 months of age, the skin lesions were mostly on the lower extremities.169 Although any number of bruises may be present in any child, the location and configuration of the bruises and the mobility of the child, taken together with the rest of the medical and social history determines the suspicion for abuse (Fig. 9-1 and Table 9-3). 
Figure 9-1
Schematic illustrates distribution of abusive versus accidental bruising.
 
(Redrawn from original courtesy of Samir Abedin, MD.)
(Redrawn from original courtesy of Samir Abedin, MD.)
View Original | Slide (.ppt)
Figure 9-1
Schematic illustrates distribution of abusive versus accidental bruising.
(Redrawn from original courtesy of Samir Abedin, MD.)
(Redrawn from original courtesy of Samir Abedin, MD.)
View Original | Slide (.ppt)
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Table 9-3
Evaluating Bruising in a Child—Implications for Practice
A bruise must never be interpreted in isolation and must always be assessed in the context of medical and social history, developmental stage, explanation given, full clinical examination, and relevant investigations.
Patterns of bruising that are suggestive of physical child abuse:
  •  
    Bruising in children who are not independently mobile
  •  
    Bruising in babies
  •  
    Bruises that are seen away from bony prominences
  •  
    Bruises to the face, back, abdomen, arms, buttocks, ears, hands
  •  
    Multiple bruises in clusters
  •  
    Multiple bruises of uniform shape
  •  
    Bruises that carry the imprint of implement used or a ligature
 

Adapted from Maguire S, Mann MK, Sibert J, et al. Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review. Arch Dis Child. 2005; 90(2):182–186.

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Although the configuration of abusive bruises may resemble the implement used to inflict the injury, the soft tissue injuries of abuse are weapon specific in fewer than 10% of patients.190 The weapons used to abuse children often include belt buckles, staplers, ropes, switches, coat hangers, ironing cords, and the open or closed human hand.136,258 Bruises inflicted by an open hand may appear on the face or a flat area of skin and grasp marks may appear as ovoid lesions when the fingertips are deeply embedded in the extremities or the shoulders of the child during extreme shaking.123 The injury pattern and the severity of the bruising depend on the amount of force used, how directly the instrument made contact, and the specific type of implement used to strike the child.123 
Other types of skin lesions may be noted. Welts are more complex skin lesions in which swelling accompanies bruising from injury through lashing or whipping. Lacerations, scars, and burns are seen in older abused children, whereas bruises are seen in all ages.190 Like bruises, the laceration configuration can resemble the weapon used to inflict the injury on the child. Although minor lacerations around the eye are fairly common, multiple scars from either lacerations or burns are suspicious.222,265 Displaced fractures may have associated bruising, with or without abuse. Deep bruising after abuse can be so extensive that rhabdomyolysis can occur, detectable by urine dipstick.216 
The age of a bruise can be roughly estimated by a change in color over the 2 to 4 weeks following injury, with fading of the lesions beginning at the periphery. Acute contusions are blue or reddish purple, gradually changing to green, then to yellow, with final resolution as a brownish stain as hemoglobin is finally broken down.278 Langlois and Gresham171 noted that a yellowish bruise must be older than 18 hours; a red, purple, blue, or black coloration of the bruise may be present from 1 hour after injury to resolution; red is always present in bruises regardless of the age; and bruises of identical age and etiology on the same person may be of different appearances and may change at different rates. A deep contusion may take some time to rise to the skin surface because of intervening fascial planes and thus delay its appearance. Although the color of a bruise may roughly aid in determining the length of time it has been present, dating bruises based on appearance should be done with caution.232,250 
Natural skin lesions should not be mistaken for bruises. Mongolian spots, more common in black or Asian infants, are deep-blue pigmented areas that are present on the lower back at birth, usually just proximal to the buttocks.17 They do not change in color and gradually resolve as the child matures.123 Cultural differences should be considered when unusual skin lesions are noted. Vietnamese children may be subjected to the folklore medical practice known as cao gio, which places scratches and bruises on the back of the trunk and may be mistaken for child abuse.45 Other conditions can mimic inflicted bruising: Eczema, coagulation disorders, vasculitis, impetigo, Ehlers–Danlos syndrome, vascular malformations, dye stains, and others.259 In cases where bruising or bleeding is the only finding of abuse, a family history for bleeding diathesis, using established protocols for hematologic evaluation for an underlying bleeding disorder and involvement of a hematologist, is advised before child maltreatment is diagnosed.172,262 

Burns

Burns are found in approximately 20% of abused patients96 and are most likely to occur in patients younger than 3 years of age.190 Burn evaluation should include configuration, approximate percentage of body surface area, location, distribution, uniformity, length of time the child was in contact with the burning agent, temperature of the burning agent, and presence or absence of splash marks when hot liquids are involved.123 
Scalds are the most frequent type of abusive burns and are caused either by a spill or an immersion.164 Accidental spill burns are generally located on the trunk and proximal upper extremities (Fig. 9-2). Most accidental pour or spill burns occur on the front of the child, but accidental burns can also occur on the back as well. In accidental flowing liquid burns, the injury usually has an arrowhead configuration in which the burn becomes shallower and more narrow as it moves downward, and there may be splash marks surrounding the lesion.123 The pattern in accidental burns may also be indicative of flowing water.224 Abuse should be suspected when deep second- or third-degree burns are well demarcated with circumferential definition. The typical child abused by scalding burns is an undernourished 2-year-old child with 15% to 20% of the body involved, usually the buttocks, and has a 10% to 15% mortality rate from secondary sepsis.224 
Figure 9-2
Schematic illustrates location of accidental versus abusive burns.
 
Note the buttock and lower extremity distribution of nonaccidental immersion burns compared to thoracic distribution accidental burns.
 
(Redrawn from original courtesy of Samir Abedin, MD.)
Note the buttock and lower extremity distribution of nonaccidental immersion burns compared to thoracic distribution accidental burns.
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Figure 9-2
Schematic illustrates location of accidental versus abusive burns.
Note the buttock and lower extremity distribution of nonaccidental immersion burns compared to thoracic distribution accidental burns.
(Redrawn from original courtesy of Samir Abedin, MD.)
Note the buttock and lower extremity distribution of nonaccidental immersion burns compared to thoracic distribution accidental burns.
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In accidental hot water immersion, an indistinct stocking or glove configuration may be seen with varying burn depths and indistinct margins. In deliberate immersion burns such as occurs when a child's buttocks are immersed in hot water, the burn demarcation has uniform depth and a well-demarcated water line.123 The gluteal crease of the buttocks may be spared, giving a doughnut-like appearance to the burn. In accidental hot water immersion, the child is uniformly scalded about the lower extremities as the legs are quickly extended by the child to climb out of the water, but in deliberate, abusive immersion the child is lowered into the water and instinctively flexes the hips and knees, thus sparing the popliteal area.96 
Burns can be inflicted by many objects commonly found in the household. Intentional burns by cigarettes are circular, deeply excavated, and sometimes repetitive, usually about 8 mm in diameter.123 Impetigo may resemble scalds or cigarette burns, but is more superficial. Severe eczema may mimic burns suspicious for child abuse.110 Contact with heated objects may cause burns of unique shape that allow identification of their etiology. Children accidentally grasping curling irons sustain burns of the palms, whereas burns on the dorsum of the hands are more suspicious for abuse.135 Hair dryers can be used to inflict burns on children, and full-thickness skin burns can result from the heated air or from contact with the grill up to 2 minutes after it has been turned off.220 Abuse burns have also been inflicted by stun guns.94 These devices deliver a high-voltage impulse of up to 100,000 V at 3 to 4 mA, incapacitating the individual and leaving hypopigmented burn scars on the skin 0.5 cm apart. Circular scars above the wrists may be because of rope burns when children are restrained for beatings.135 Full-thickness skin burns have been reported in small children who were placed in microwave ovens.7 Certain folklore practices may cause lesions simulating abusive burns. Round burns on the abdomen, buttock, or between the thumb and forefinger of Southeast Asian children may be because of a variant on the Chinese medical practice of moxibustion. Folk medical practitioners' burn balls of the moxa herb on the surface of the skin for therapeutic purposes, and both cigarettes and yarn have been similarly used in refugee camps. The knowledge of these practices may help to avoid inappropriate accusations of child abuse.86 
The orthopedic surgeon must examine and carefully document all soft tissue injuries that are present before treating acute fractures. Casts applied in the treatment of fractures, especially a spica cast, may obscure potentially incriminating skin lesions and will preclude other members of the child advocacy team from being able to identify or document them. Photographs taken to document skin lesions must be done before cast placement. 

Abusive Head Trauma

Several terms have been used to describe head trauma related to abuse, including the older term shaken baby syndrome (SBS) and the preferred newer terms AHT,37 inflicted traumatic brain injury (ITBI), inflicted head trauma (IHT), or nonaccidental head trauma.201 These terms have been used to describe a form of physical NAT in infants with a triad of subdural hemorrhage, retinal hemorrhage, and encephalopathy occurring with an inconsistent or inappropriate history, commonly associated with other inflicted injuries.106 The American Academy Committee on Child Abuse and Neglect recommends the term “abusive head trauma” to be used in the medical record. Pediatric AHT is defined as “an injury to the skull or intracranial contents of an infant or young child, less than 5 years of age, because of an inflicted blunt impact and/or violent shaking.61,214 Recent excellent review articles discuss fatal AHT95 and the diagnosis of pediatric head trauma in general.125,126 The rate of hospitalization for AHT (36 per 100,000) is similar to that of fractures from NAT (25 to 32 per 100,000).175 
A child under the age of 3 years who suffers head trauma from abuse is more likely to have sustained a noncontact injury mechanism (acceleration–deceleration or shaking) resulting in deeper brain injury, cardiorespiratory compromise with diffuse cerebral hypoxia–ischemia, and a worse outcome at 6 months than a child who is accidentally injured.126 Head injuries can be from indirect noncontact forces such as in shaking or from direct contact from a blow to the head such as occurs when the child is thrown against an object. Indirect trauma is felt to be responsible for the most severe injuries, although the actual injury may be from both mechanisms. Symptoms typically occur early rather than later, although secondary or delayed brain injury may occur with edema and the brain's neurotoxic injury response. 
In physical abuse, the most common cause of death is head trauma.223 In Kleinman's154 classic postmortem study of 31 infants with an average age of 3 months, head trauma was the cause of death in 18. For children less than 2 years of age dying from a traumatic brain injury, 80% of the deaths are from abuse, with the highest incidence at 6 months.93 For a child with AHT, the mortality rate is approximately 20%, and survivors have a higher rate of permanent and significant disability than is seen with accidental trauma.140 
When an infant presents with altered mental status, AHT should be suspected (Table 9-4). Jenny et al.132 reported that 31.2% of cases of AHT were misdiagnosed on initial presentation to the emergency room, with a delay averaging 7 days until a correct diagnosis was made. Although early diagnosis of an infant with AHT is essential, primary prevention is the most important new development to occur nationally. There is correlation between peak incidence of infant crying and peak incidence of AHT that occurs 4 to 6 weeks later, suggesting that repeat and prior injuries occur.25 Dias et al.,77 utilizing an early postnatal hospital-based program for new parents to learn about shaking impact syndrome and how to appropriately deal with an inconsolable infant, found a 47% decrease in SBS, whereas intervention programs after abuse was recognized having much less success.182 
 
Table 9-4
Criteria for Categorizing the Etiology of Head Injuries
Category Criteria
Noninflicted Cases in which the child's primary caregiver described an accidental head injury event that was developmentally consistent, historically consistent with repetition over time, could be linked to the child's acute clinical presentation for traumatic cranial injuries, and occurred in the absence of any noncranial injuries considered moderately or highly specific for abusea.
Cases in which an accidental head injury event was witnessed independently and could be linked to the child's acute clinical presentation for traumatic cranial injuries (e.g., motor vehicle accident).
Inflicted Cases in which the child's primary caregiver admitted abusive acts that could be linked to the child's acute clinical presentation for traumatic cranial injuries.
Cases in which an independent witness verified abusive acts that could be linked to the child's acute clinical presentation for traumatic cranial injuries.
Cases in which a child not yet cruising or walking became clearly and persistently ill with signs of acute cardiorespiratory compromiseb linked to his or her traumatic cranial injuries while in the care of a primary caregiver who denied any knowledge of a head injury event.
Cases in which the child's primary caregiver provided an explanation for the child's head injury event that was clearly developmentally inconsistent with the parents' description of their child's developmental capabilities.
Cases in which the child's primary caregiver provided an explanation for the child's head injury event that was highly inconsistent with repetition over time.
Cases in which the head-injured child also revealed at least two noncranial injuries considered moderately or highly specific for abusea.
Undetermined Cases meeting criteria for both inflicted and noninflicted etiology.
Cases not meeting any criteria for either inflicted or noninflicted etiology.
 

Adapted from Hymel KP, Makoroff KL, Laskey AL, et al. Mechanisms, clinical presentations, injuries, and outcomes from inflicted versus noninflicted head trauma during infancy: Results of a prospective, multicentered, comparative study. Pediatrics. 2007; 119(5):922–929.

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As a general principle, a typical short fall in the home is highly unlikely to cause generalized CNS injury or subdural or retinal hemorrhage, although isolated skull fracture or epidural hemorrhage may be seen. The young infant who is not developmentally mobile enough to cause a fall from a height, having a relatively large head, immature brain, and weak neck muscles, is very vulnerable to the whiplash effects of inflicted violent shaking (Fig. 9-3). In 25% to 54% of confirmed cases of AHT, the abuser described an indirect mechanism by shaking the infant without the head contacting a surface, with resulting immediate onset of symptoms.36,247 Indirect trauma is responsible for the most severe injuries. There is sudden angular acceleration and deceleration with associated rotation of the head and neck in relation to the thorax, producing inertial shear strain deformation and disruption leading to diffuse injury.23 Whereas accidental trauma causes subdural hemorrhage from the translational forces of an impact, IHT from rotational and shearing forces may result in more diffuse subdural or intrahemispheric hemorrhage.120 
Figure 9-3
Illustration of acceleration–deceleration injury sustained by a shaken infant.
 
Shaken infants suffer whiplash injuries due in part to their disproportionately large heads in relation to their bodies. This mechanism is believed responsible for the common association of subdural hematomas, retinal hemorrhages, and posterior rib fractures.
 
(Artwork courtesy of Gholamreza Zinati, MD.)
Shaken infants suffer whiplash injuries due in part to their disproportionately large heads in relation to their bodies. This mechanism is believed responsible for the common association of subdural hematomas, retinal hemorrhages, and posterior rib fractures.
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Figure 9-3
Illustration of acceleration–deceleration injury sustained by a shaken infant.
Shaken infants suffer whiplash injuries due in part to their disproportionately large heads in relation to their bodies. This mechanism is believed responsible for the common association of subdural hematomas, retinal hemorrhages, and posterior rib fractures.
(Artwork courtesy of Gholamreza Zinati, MD.)
Shaken infants suffer whiplash injuries due in part to their disproportionately large heads in relation to their bodies. This mechanism is believed responsible for the common association of subdural hematomas, retinal hemorrhages, and posterior rib fractures.
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The eye of a young infant has a soft sclera: The globe can more easily deform during shaking. This causes vitreoretinal traction leading to direct hemorrhage in the retina and in the optic nerve sheath.282 Fundoscopic examination confirms and documents retinal optic nerve as well as orbital hemorrhage.46 Retinal hemorrhages of abuse classically are multilayered, more anterior, closer to the ora serrata, and are numerous and bilateral. Retinoschisis is a splitting of the layers of the macula forming a cystic cavity caused by shearing and pulling forces of the strong vitreous attachments to the retinal surface and is classic for AHT.229 Unilateral retinal hemorrhages may occur in 10% to 16% of cases, so unilateral does not rule out SBS.16 Although retinal hemorrhages resulting from normal vaginal birth are present in 34% of newborns, these resolve by 16 days of age.121 
Previous clinical studies on SBS do not typically address injury to the cervical spine, so it is not known how frequently the spine also is injured with this mechanism.21 In very young infants (2 to 3 months of age), forces may be directed to the upper cervical spine leading to spinal cord injury without obvious radiographic abnormality (SCIWORA), cervicomedullary junction cord injury, apnea, and cardiorespiratory arrest.97,126 Direct head injuries may also occur when the child's head is slammed onto a soft surface such as a mattress.83 On impact, deceleration forces approaching 400 Gs may occur, tearing the bridging vessels between the skull and the brain and producing intracranial hemorrhage and cerebral edema. Skull fractures are rare unless the child is thrown onto a hard object. 
A complete neurologic examination is required for any child suspected of being abused. This should include assessment of the child's mental status, motor function, sensation, reflexes, and gait, if possible. Any abnormal findings warrant further investigation. Also included should be a dilated fundoscopic examination by an ophthalmologist looking for retinal hemorrhages. For the child with acute neurologic findings suspicious for AHT, a noncontrast computed tomography (CT) scan is done to evaluate for conditions that may benefit from prompt medical and neurosurgical treatment, such as intracranial hemorrhage—acute parenchymal, subarachnoid, subdural, or epidural (Fig. 9-4). If the head CT scan includes upper cervical spine-associated injuries, pre-existing bony conditions such as Klippel–Feil syndrome or occipital cervical assimilation may be detected.119 Anteroposterior (AP) and lateral skull and spinal radiographs are always included as part of the routine skeletal survey for the child less than 2 years of age and should be performed for any aged child with suspected AHT (Table 9-5). CT scans alone may occasionally miss in-plane axial skull fractures. However, these fractures are usually easily seen on the accompanying skeletal survey. Although fine-cut three-dimensional CT skull reconstructions may reveal subtle skull fractures, they may increase delivered radiation by up to 30% over standard head CT. New CT scanners and reformatting algorithms allow for 3D images of the calvarium at no extra radiation dose. Magnetic resonance imaging (MRI) is best used to fully assess various intracranial pathology and has become the imaging modality of choice for evaluating asymptomatic, nonacute parenchymal brain lesions and for fully documenting the abuse. MRI is also effective for diagnosis of related conditions in the cervical spine, including ligamentous injury and intraspinal injuries such as SCIWORA. 
Figure 9-4
Interhemispheric subdural hematoma in an 8-month-old female presenting with seizures caused by nonaccidental trauma.
 
Axial CT image shows high attenuation blood along the left aspect of the posterior falx (arrow).
Axial CT image shows high attenuation blood along the left aspect of the posterior falx (arrow).
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Figure 9-4
Interhemispheric subdural hematoma in an 8-month-old female presenting with seizures caused by nonaccidental trauma.
Axial CT image shows high attenuation blood along the left aspect of the posterior falx (arrow).
Axial CT image shows high attenuation blood along the left aspect of the posterior falx (arrow).
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Table 9-5
Complete Skeletal Survey Table
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Table 9-5
Complete Skeletal Survey Table
Appendicular Skeleton
  •  
    Humeri (AP)
  •  
    Forearms (AP)
  •  
    Hands (PA)
  •  
    Femurs (AP)
  •  
    Lower legs (AP)
  •  
    Feet (AP)
Axial Skeleton
  •  
    Thorax (AP, lateral, right and left obliques), to include ribs, thoracic and upper lumbar spine
  •  
    Pelvis (AP), to include the mid lumbar spine
  •  
    Lumbosacral spine (lateral)
  •  
    Cervical spine (lateral)
  •  
    Skull (frontal and lateral)
 

Adapted from American Academy of Pediatrics. Section on Radiology. Diagnostic imaging of child abuse. Pediatrics. 2000; 105(6):1345–1348.

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Even in abused children without neurologic findings or retinal hemorrhages, occult head injury should always be suspected. At risk children with obvious neurologic findings should be urgently screened with head CT for acute pathology. At risk children without obvious neurologic findings are best imaged initially with MR brain imaging (ACR guidelines).12 MRI is sensitive for diagnosing small parenchymal hemorrhages83 and offers the highest sensitivity and specificity for the diagnosis of subacute and chronic head injuries.12 Diffusion- and susceptibility-weighted imaging sequences are extremely sensitive for detecting subtle hypoxic–ischemic brain injury and parenchymal hemorrhage213,256 and are routinely included in imaging protocols when available. MR venography may be used if venous sinus thrombosis is suspected. MR spectroscopy may detect lactate levels, an indicator of prognosis.87 
Infants with acute head injuries may have fever, bulging fontanelles, and macrocephaly. Paresis may be present, and reflexes may be increased. Older infants and children may have subdural hemorrhages and musculoskeletal injuries.97 Classic infant AHT with multilayered retinal hemorrhages and acute subdural hematomas has been noted in an autopsy series of four older children between 2.5 and 7 years of age.229 Cerebral edema may be lethal,60 so emergency neurosurgical consultation may be needed. Barnes and Krasnokutsky23 reviewed the radiographic evaluation of a young child with a suspected nonaccidental head injury, including mimicking of conditions, such as accidental injury from short falls, acute CNS infections, coagulopathies, venous thrombosis, metabolic abnormalities, and neoplasms. The diagnosis of these mimics may require more extensive workup before a diagnosis of AHT is confirmed (Table 9-6).242 Oehmichen et al.204 have presented very practical principles for diagnosing AHT (Table 9-7). 
Table 9-6
Differential Diagnosis of Subdural Hemorrhage in Infants and Children
  •  
    Accidental or abusive trauma
  •  
    Birth trauma (in child <6 weeks of age)
  •  
    Congenital malformations (e.g., arteriovenous malformations) in older children
  •  
    Coagulopathies (vitamin K deficiency in the newborn, disseminated intravascular coagulation, hemophilia)
  •  
    Infection (septicemia, meningitis, necrotizing encephalitis)
  •  
    Metabolic disorders (glutaric aciduria type 1, OI, Menke kinky-hair syndrome)
  •  
    Tumor—very rare. Seen in older child.
  •  
    Vasculitis (Kawasaki disease)
  •  
    Venous sinus thrombosis with hemorrhagic infarct
 

Adapted from Sirotnak AP, Grigsby T, Krugman RD. Physical abuse of children. Pediatr Rev. 2004; 25:264–277.

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Table 9-7
Principles of Diagnosing Inflicted Traumatic Brain Injury in Children
  1.  
    Simple injuries are caused by simple mechanism; extreme violence (blows, shaking, impact) is necessary to cause life-threatening injuries.
  2.  
    Life-threatening injuries are characterized by the rapid onset of serious clinical symptoms (coma, circulatory and respiratory arrest) without a lucid interval.
  3.  
    If a parent or caregiver attributes a severe traumatic brain injury in a child to a household fall, the claim should be regarded as suspect until proven otherwise.
  4.  
    If a child is injured by a fall, the parent or caregiver will immediately seek medical care and express extreme anxiety regarding the fate of the child. But if a child is injured by abuse, the perpetrator often waits to see if the child will recover spontaneously.
  5.  
    The diagnosis of shaking trauma is rarely based on a confession, more on the implausibility of an explanation. Shaking is hardly ever witnessed.
  6.  
    The following symptom complex is highly specific to shaking trauma:
    •  
      Intracranial hemorrhage, especially subdural or subarachnoid
    •  
      Retinal hemorrhage
    •  
      Dural bleeding of the cervical cord
    •  
      Bleeding of the throat and neck muscles
    •  
      Gripping marks on the thorax and shoulders
    •  
      Symptoms of recurrent trauma
 

Adapted from Oehmihen M, Meissner C, Saternus KS. Fall or shaken: Traumatic brain injury in children caused by falls or abuse at home—a review on biomechanics and diagnosis. Neuropediatrics. 2005; 36:240–245.

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Disability after AHT is frequent and ranges from mild to severe. Common late sequelae after AHT include developmental delays, sensory and motor deficits, feeding difficulties, recurrent seizures, attention deficits, and intellectual, educational, and behavioral dysfunctions.126 In a long-term outcome study, 69% of children had an abnormality and 40% had severe dysfunction.22 Approximately 50% had visual impairment and another 50% had behavior disorder.22 Some children seemed normal until 5 years after the inflicted injury, then showed learning disorders, so long-term follow-up is essential. Repeat abuse when AHT is not recognized and the child is returned to the home is too common.97 

Abdominal Injuries

After AHT, trauma to the abdomen is the second most common reason for death from abuse.39 In a review of the National Pediatric Trauma Registry, 16% of all blunt abdominal trauma in children 0 to 4 years of age was attributable to child abuse.268 The pediatric thorax and pelvis are very compliant. The abdominal muscles are pliable with little subcutaneous and omental fat, so there is less protection to the internal abdominal, chest, and pelvic organs. Whereas shaken infants sustain head trauma, toddlers receive abdominal injuries as they are more often punched and beaten. Inflicted abdominal trauma may be because of beatings with the hand, fist, or when the child is thrown into a fixed object. The compliant pediatric abdominal wall does not absorb much of the injury energy, so abdominal bruising is present in only 12% to 15% of major intra-abdominal injury cases.123 Children with inflicted injuries are more likely to be of a younger age, malnourished, have a pancreatic or hollow viscous injury, have an associated traumatic brain injury, and have higher mortality compared to victims of accidental abdominal injury.268 
Children with abdominal injury from child abuse may have a wide range of symptoms depending on the organ involved and the severity of the injury. Fever, vomiting, anemia, abdominal distention, localized involuntary spasm, and bowel sounds may be absent.207 The liver is the most commonly injured solid organ. With a damaged liver, right shoulder pain from hemidiaphragm irritation (Kehr sign) may be associated with abdominal pain and fatal hypovolemic shock.266 Liver function tests may reveal occult liver injury. In one study,64 elevated aspartate aminotransferase, alanine aminotransferase, and lactic dehydrogenase enzyme levels were useful markers for occult liver lacerations in abused children who had false-negative abdominal examinations. Blows to the abdomen often injure the pancreas as it is violently compressed against the spine. Blunt pancreatic injury caused by NAI commonly presents with contusion, transaction, or laceration, all of which are associated with pancreatitis and elevated blood amylase. A pancreatic pseudocyst may form, causing obstructive symptoms several weeks after initial injury.123 Splenic and renal injuries, rare in child abuse, have a 45% risk of mortality from hemorrhagic or septic shock if care is delayed.67 
Hollow organ injuries to the upper or lower gastrointestinal tract or bladder are infrequent in accidents but common in child abuse, particularly in the younger child (mean age 2.5 years).173 Hollow organ abuse injuries, as is true for most abdominal injuries caused by NAI, presented for medical attention late, with an inconsistent or vague history. In a young child with unexplained hollow organ injury, abuse should be suspected and investigated. 
Child abuse is the leading cause of duodenal injury in children less than 4 years of age.267 Intramural duodenal hematoma may cause obstruction and bilious vomiting.123 CT, ultrasound imaging, and/or upper gastrointestinal radiography may be diagnostic (Fig. 9-5). More severe trauma may cause duodenal avulsion or transection with nausea, vomiting, and clinical acute abdomen.181 Frequently, the radiologist first suggests the possibility of NAT by finding a duodenal hematoma with no history by the caregiver of trauma. Blunt trauma to the abdomen may also cause intestinal perforation, usually involving the small intestine, and the physical examination may suggest peritonitis. Previously, plain radiographs were used to search for free air in suspected hollow organ injuries; however, only 19% of radiographs were diagnostic.41 Today, CT with intravenous contrast enhancement is used for the trauma evaluation. CT imaging better reveals free fluid, focal bowel wall thickening, inflammation, or ileus. Associated spine injuries, such as Chance flexion–distraction lumbar spine fracture, should be evaluated. 
Figure 9-5
Duodenal hematoma and pancreatic transection in a 4-year-old male presenting with bilious vomiting caused by nonaccidental abdominal trauma.
 
A: Fluoroscopic upper gastrointestinal image reveals a large, well-defined defect within the third portion of the duodenum (arrows). Axial contrast-enhanced CT images at the level of the duodenum (B) and pancreas (C) show a large hyper attenuated retroperitoneal duodenal hematoma (arrows) and a linear low attenuation defect (arrowhead) in the pancreatic head. Also noted is peripancreatic fluid.
A: Fluoroscopic upper gastrointestinal image reveals a large, well-defined defect within the third portion of the duodenum (arrows). Axial contrast-enhanced CT images at the level of the duodenum (B) and pancreas (C) show a large hyper attenuated retroperitoneal duodenal hematoma (arrows) and a linear low attenuation defect (arrowhead) in the pancreatic head. Also noted is peripancreatic fluid.
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Figure 9-5
Duodenal hematoma and pancreatic transection in a 4-year-old male presenting with bilious vomiting caused by nonaccidental abdominal trauma.
A: Fluoroscopic upper gastrointestinal image reveals a large, well-defined defect within the third portion of the duodenum (arrows). Axial contrast-enhanced CT images at the level of the duodenum (B) and pancreas (C) show a large hyper attenuated retroperitoneal duodenal hematoma (arrows) and a linear low attenuation defect (arrowhead) in the pancreatic head. Also noted is peripancreatic fluid.
A: Fluoroscopic upper gastrointestinal image reveals a large, well-defined defect within the third portion of the duodenum (arrows). Axial contrast-enhanced CT images at the level of the duodenum (B) and pancreas (C) show a large hyper attenuated retroperitoneal duodenal hematoma (arrows) and a linear low attenuation defect (arrowhead) in the pancreatic head. Also noted is peripancreatic fluid.
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The Academy of Pediatrics Section on Radiology12 recommends CT scans with nonionic intravenous contrast to define injury to abdominal organs. Contrast should not be used if there is a history of iodine allergy or renal failure. The use of oral contrast is debatable with CT scans and may place the patient at risk of aspiration. Ultrasound and upper gastrointestinal series are most often used to evaluate duodenal hematoma. When abdominal injury is suspected in an abused child, the hematocrit and hemoglobin levels are checked, the child is typed and crossmatched for blood, and two large intravenous lines are placed in anticipation for surgical treatment. General surgery consultation is obtained. The overall mortality rate associated with visceral injury in child abuse is 40% to 50%.64 In fatal cases with liver injury, hepatic glycogen staining may be helpful in establishing time of death for legal reasons.261 Occult abdominal trauma is easily missed, so a high index of suspicion with serial abdominal examination and liberal use of abdominal CT should be used in the suspected abused child.120 

Genital Injuries

Sexual abuse should always be considered when evaluating a physically abused child. Specific guidelines for the evaluation for sexual abuse were revised and published in 2005.2 Children who have been sexually abused can have symptoms of bed wetting, fecal incontinence, painful defecation, pelvic pain, abdominal pain, vaginal itching and bleeding, sexually transmitted diseases, and pregnancy in postmenarche adolescents. Sexually transmitted diseases found in abused children include gonorrhea, syphilis, chlamydia, trichomoniasis, and lymphogranuloma venereum. Although the percentage of sexually assaulted children with obvious physical trauma to the genitalia is low, failure to document such findings is a serious matter. Sexual abuse is always a criminal offense and must be reported to legal authorities. The physical signs of sexual abuse, including genital trauma, sexually transmitted diseases, or presence of sperm, are present in only 3% to 16% of verified sexual assaults,29,241 but even this minority of patients will be undiagnosed if sexual abuse is not considered when a child presents with musculoskeletal injury resulting from abuse. 
The orthopedic surgeon should be aware of the proper procedure for handling suspected sexual abuse, but is not expected to manage this evaluation. When sexual abuse is suspected, consultation with an experienced medical team will assure competent assessment of the child's physical, emotional, and behavioral needs, manage reporting and legal requirements, and interact with appropriate professionals to provide comprehensive treatment and follow-up.2 The child's genitalia should always be examined and documented in a chaperoned setting by an appropriate physician consultant such as a pediatrician or a gynecologist. If the sexual assault occurred within 72 hours of evaluation, then a rape kit must be used by the evaluating physician or nurse examiner to provide medical evidence of the attack.167 However, detecting semen on examination for forensic evidence decreases markedly after 24 hours.211 
Patterns of injury that suggest, but are not specific for, sexually motivated assault include bruises, scratches, and burns around the lower trunk, genitalia, thighs, buttocks, and upper legs, including the knees. Pinch or grip marks may be found where the child was held. Attempted or achieved penetration may involve the mouth, vagina, or anus.117 Sexually abused boys may have poor rectal sphincter tone, perianal scarring, or urethral discharge. Female genital examination findings that are consistent with sexual abuse include chafing, abrasion, or bruising of the inner thighs or genitalia, distortion of the hymen, decreased or absent hymen, scarring of the external genitalia, and enlargement of the hymenal opening.11 The size of the transverse hymenal orifice does not correlate as a marker of child abuse.127 The examination of the female genitalia can be normal even when there has been penetration, because hymen tissue is elastic and there can be rapid healing. In a study of 36 adolescent pregnant girls evaluated for sexual abuse, only 2 of 36 had genital changes diagnostic of penetrating trauma, suggesting that injuries either may not occur or may heal completely.141 There is also a wide variability of appearance of normal female genitalia,48,60 but posterior hymen disruption is rare and should raise suspicion for abuse.33 

Fractures in Child Abuse

Overview

After skin lesions, fractures are the second most common physical presentation of abuse. Fractures, documented on plain radiographs or CT, are present in 11% to 55% of abused children and are most common in children younger than 3 years of age.4,73,100 The child abuse literature shows varying incidence of abuse-related fractures, depending on the age of the study population, institution, study entry criteria, selection bias, and time period when the study was published.174 The younger the child with a fracture, especially under 18 months of age, the more likely abuse is the cause.62,65,143 Fractures resulting from abuse should be suspected in young children if a caretaker brings the child for evaluation but reports no history of accidental trauma, especially if the caretaker reports a change in the child such as extremity swelling or decreased movement of the limb. Particularly concerning is a bone that fractures under tension with torsion, rather than the physiologic loading of compression of normal childhood activity or falls. Pierce et al.219 recommend that the clinician determine if the observed injury of a long bone and the stated mechanism are consistent (Table 9-8). 
Table 9-8
Considerations when Evaluating a Child with a Long-Bone Fracture
  1.  
    What are the biodynamics of the injury event, the energies generated by the event, and how could certain factors of the injury environment contribute to the likelihood of injury?
  2.  
    What injuries are expected, and what is the likelihood that the event generated the specific load required to cause each and all of the injuries?
  3.  
    Did the energy of the event exceed the injury threshold, or was there a biologic abnormality such as decreased bone density that resulted in a lowering of the actual threshold for injury? Is there evidence of bone weakness or disease?
  4.  
    Is the fracture morphology consistent with the direction, magnitude, and rate of loading of the described mechanism?
  5.  
    Is the facture pattern unusual, and one that requires an extremely unusual loading condition, as is the case with a classic metaphyseal lesion (also termed corner or bucket-handle fracture)?
  6.  
    What are the child's developmental capabilities, and could the child have generated the necessary energy independent of “outside” forces to cause the observed injury?
  7.  
    Does the fracture reflect a high-energy fracture? Did the event generate enough energy to cause a high-energy fracture? Or is the fracture a small cortical defect, or hairline crack, reflecting a smaller amount of energy required for propagation of the fracture type?
  8.  
    What regions of the bone have been injured and what are the structural components that affect the ultimate pattern of fracture that is being observed? Were there structural factors that contributed to the likelihood of fracture?
 

Adapted from Pierce MC, Bertocci GE, Vogeley E, et al. Evaluating long bone fractures in children: A biomechanical approach with illustrative cases. Child Abuse Negl. 2004; 28(5):505–524.

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Kleinman ranked the specificity of skeletal fractures for abuse (Table 9-9) based on the location and type of fracture. He emphasized that both moderate and low specificity radiographic findings become more specific when there is an inadequate or inconsistent explanation for the injury. The location and the type of fracture can aid in distinguishing between an accident and child abuse, but is only one piece of information. 
 
Table 9-9
Specificity of Skeletal Trauma for Abuse
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Table 9-9
Specificity of Skeletal Trauma for Abuse
High Specificity
  •  
    Classic metaphyseal lesions
  •  
    Posterior rib fracture
  •  
    Scapular fracture
  •  
    Spinous process fracture
  •  
    Sternal fracture
Moderate Specificity
  •  
    Multiple fractures, especially bilateral
  •  
    Fractures in various stages of healing
  •  
    Epiphyseal separation
  •  
    Vertebral body fracture or subluxation
  •  
    Digital fracture
  •  
    Complex skull fracture
Low Specificity
  •  
    Clavicular fracture
  •  
    Long-bone shaft fracture
  •  
    Linear skull fracture
 

Adapted from O'Connor JF, Cohen J. Dating fractures. In: Kleinman PK, ed. Diagnostic Imaging of Child Abuse. Baltimore, MD: Williams & Wilkins; 1987:168–177, with permission.

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All types of fractures have been reported in the child abuse literature, and it is often the presence of multiple fractures that indicates NAT (Fig. 9-6). In one of the largest series, King et al.147 reported 429 fractures in 189 abused children. Fifty percent of these patients had a single fracture, and 17% had more than three fractures. Approximately 60% of fractures were found in roughly equal numbers in the humerus, femur, and tibia. Fractures also occurred in the radius, skull, spine, ribs, ulna, and fibula, in order of decreasing frequency. Another study207 found a similar incidence of fractures of the humerus, femur, and tibia in abused children, with skull fractures seen in 14%. In contrast, Akbarnia et al.3 found that rib fractures in abused patients were twice as prevalent as fractures of any one long bone; the next most frequently fractured bone was the humerus, followed by the femur and the tibia. Nearly a third of these patients had skull fractures. Loder and Bookout181 reported the tibia to be the bone most commonly fractured in their series of abused children, followed by the humerus, the femur, the radius, and the ulna. In a classic study of 31 postmortem infants, the fracture pattern was very different from clinical studies in living children.154 Highly detailed skeletal, specimen, and histopathologic analysis revealed 165 total fractures, most commonly in ribs, distal femur, the ends of the tibia, and skull (Fig. 9-7). The fact that 29 of the 31 infants had evidence of a healing fracture provides sobering evidence of the need to aggressively diagnose NAT before an infant is killed. 
Figure 9-6
Multiple fractures in a 3-month-old female victim of inflicted injury.
 
A: Frontal radiograph of the humerus shows proximal metaphyseal irregularity consistent with a corner fracture (arrow) and an oblique diaphyseal fracture with extensive periosteal reaction and healing (arrowhead). B: Axial CT image reveals a depressed left calvarial fracture (arrow). C: Lateral thoracolumbar radiograph suggests a T12 compression fracture (arrow), which is confirmed on nuclear bone scintigraphy (D) as a region of increased uptake (arrow). Bone scan also confirms left parietal (arrowhead) and humeral (curved arrow) fractures.
A: Frontal radiograph of the humerus shows proximal metaphyseal irregularity consistent with a corner fracture (arrow) and an oblique diaphyseal fracture with extensive periosteal reaction and healing (arrowhead). B: Axial CT image reveals a depressed left calvarial fracture (arrow). C: Lateral thoracolumbar radiograph suggests a T12 compression fracture (arrow), which is confirmed on nuclear bone scintigraphy (D) as a region of increased uptake (arrow). Bone scan also confirms left parietal (arrowhead) and humeral (curved arrow) fractures.
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A: Frontal radiograph of the humerus shows proximal metaphyseal irregularity consistent with a corner fracture (arrow) and an oblique diaphyseal fracture with extensive periosteal reaction and healing (arrowhead). B: Axial CT image reveals a depressed left calvarial fracture (arrow). C: Lateral thoracolumbar radiograph suggests a T12 compression fracture (arrow), which is confirmed on nuclear bone scintigraphy (D) as a region of increased uptake (arrow). Bone scan also confirms left parietal (arrowhead) and humeral (curved arrow) fractures.
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Figure 9-6
Multiple fractures in a 3-month-old female victim of inflicted injury.
A: Frontal radiograph of the humerus shows proximal metaphyseal irregularity consistent with a corner fracture (arrow) and an oblique diaphyseal fracture with extensive periosteal reaction and healing (arrowhead). B: Axial CT image reveals a depressed left calvarial fracture (arrow). C: Lateral thoracolumbar radiograph suggests a T12 compression fracture (arrow), which is confirmed on nuclear bone scintigraphy (D) as a region of increased uptake (arrow). Bone scan also confirms left parietal (arrowhead) and humeral (curved arrow) fractures.
A: Frontal radiograph of the humerus shows proximal metaphyseal irregularity consistent with a corner fracture (arrow) and an oblique diaphyseal fracture with extensive periosteal reaction and healing (arrowhead). B: Axial CT image reveals a depressed left calvarial fracture (arrow). C: Lateral thoracolumbar radiograph suggests a T12 compression fracture (arrow), which is confirmed on nuclear bone scintigraphy (D) as a region of increased uptake (arrow). Bone scan also confirms left parietal (arrowhead) and humeral (curved arrow) fractures.
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A: Frontal radiograph of the humerus shows proximal metaphyseal irregularity consistent with a corner fracture (arrow) and an oblique diaphyseal fracture with extensive periosteal reaction and healing (arrowhead). B: Axial CT image reveals a depressed left calvarial fracture (arrow). C: Lateral thoracolumbar radiograph suggests a T12 compression fracture (arrow), which is confirmed on nuclear bone scintigraphy (D) as a region of increased uptake (arrow). Bone scan also confirms left parietal (arrowhead) and humeral (curved arrow) fractures.
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Figure 9-7
Schematic representation of the distribution of 165 fractures in 31 infant fatalities.
 
Single vertebral fracture and 13 skull fractures in this case series are not shown.
 
(Image reprinted from Kleinman PK, Marks SC Jr, Richmond JM, et al. Inflicted skeletal injury: A postmortem radiologic-histopathologic study in 31 infants. AJR AM J Roentgenol. 1995; 165(3):647–650, with permission).
Single vertebral fracture and 13 skull fractures in this case series are not shown.
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Figure 9-7
Schematic representation of the distribution of 165 fractures in 31 infant fatalities.
Single vertebral fracture and 13 skull fractures in this case series are not shown.
(Image reprinted from Kleinman PK, Marks SC Jr, Richmond JM, et al. Inflicted skeletal injury: A postmortem radiologic-histopathologic study in 31 infants. AJR AM J Roentgenol. 1995; 165(3):647–650, with permission).
Single vertebral fracture and 13 skull fractures in this case series are not shown.
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Physician education in child abuse is necessary to properly identify and report child abuse,170 as there are many pitfalls to avoid (Table 9-10). There are several medical conditions that result in weakened bone and predisposition to fracture, such as OI, that should be considered in the evaluation of a young child with multiple fractures.129 Some metabolic diseases cause metaphyseal abnormalities that should not be confused for metaphyseal fractures. One must also be aware of the normal physiologic diaphyseal periosteal reaction that is frequently present in infants younger than 6 months. In contrast to healing fractures, this is typically symmetric, diaphyseal only, and seen on the long bones of the extremities.217 
 
Table 9-10
Pearls and Pitfalls of Nonaccidental Trauma
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Table 9-10
Pearls and Pitfalls of Nonaccidental Trauma
  •  
    Be particularly cautious of a young infant with an injury.
  •  
    It is unusual for a young child to sustain a life-threatening injury from a fall alone, and he or she is highly unlikely to die from a short-height fall.
  •  
    Caregiver should be able to describe in detail the mechanism that is consistent with the observed injury.
  •  
    Multiple rib fractures, fractures in various stages of healing, and classic metaphyseal fractures are highly specific.
  •  
    Injury mechanism stated by the parents should agree with the type and energy of the fracture.
  •  
    Failure to diagnose child abuse may result in 25% risk of repeat abuse and 5% chance of death.
  •  
    Concerning bruises and skin lesions are the most common presentation of abuse. However, the child with such bruises should receive a proper evaluation for bleeding disorder.
  •  
    Unexplained fractures are much more likely to represent abuse and not a rare disease such as osteogenesis imperfecta (OI). Always consider OI when multiple fractures are seen.
  •  
    Obtain skeletal survey in all children younger than 2 years old, and individualize for 2–5-year-olds when child abuse is suspected. Repeat in 2 weeks.
  •  
    Involve the hospital child protective team early in the evaluation.
  •  
    Prepare records as though everything will be reviewed and read in court.
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Compared to healthy term infants, premature infants are more susceptible to fractures, both related to their prematurity and to increased risk of child abuse.51 They may have underlying genetic, metabolic, and nutritional deficiency that predispose to fractures. Underlying osteopenia may lead to insufficiency fractures, both acute and chronic, in various stages of healing. Higher parental stress from caring for a sick or disabled infant may result in higher risk of NAT. In the premature infant with multiple fractures, investigation of the bone health as well as for child abuse is necessary, depending on the clinical context and findings. 

The Skeletal Survey

In addition to standard radiographic studies of the acute injury, a complete skeletal survey should be used to screen for additional fractures in all children younger than age 2 years when abuse is suspected.12,142 Use of the skeletal survey in children suspected of abuse yielded positive findings in 10.8% of cases, most commonly in children with AHT, a life-threatening event, and in infants under 6 months of age in which the physical examination is less reliable.82 Besides the index child, children under the age of 2 years in the same household of the injured abused child have a 11.9% risk of a positive skeletal survey, so are also recommended to have a skeletal survey.180 The standard views obtained on a skeletal survey recommended by the American College of Radiology13 are listed in Table 9-5. A suspected metaphyseal lesion of the extremity is more likely to be detected when a lateral view is done in addition to the AP view.139 Lateral views coned to the joints may help in diagnosing classic metaphyseal lesions (CMLs). Lateral views of the entire spine must always be included in the skeletal survey. Bilateral oblique views of the thorax are for the diagnosis of subtle rib fractures.142 The American Academy of Pediatrics Section on Radiology12 cautioned that a “baby gram” has no place in diagnosing fractures of child abuse because the obliquity of the angle at which the radiographs transverse the skeleton may obscure many subtle fractures.66 
Screening skeletal survey (Table 9-5) is the standard of care for imaging suspected child abuse in children less than 2 years of age. A radionucleotide bone rarely is used as a complementary and confirmatory test for problem solving some difficult cases.66 Neither a skeletal survey nor a technetium bone scan alone will detect all occult fractures.142 In Kleinman's postmortem infant study of fractures diagnosed by detailed histopathology, 58% of these fractures were seen on skeletal survey and 92% were seen by specimen radiographs. Because of a false-negative rate of 12% with skeletal surveys, Sty and Starshak254 suggested in 1983 that a technetium bone scan be used as an initial screening test. However, technetium bone scintigraphy is currently used much less frequently in tertiary children's hospitals. Technetium bone scintigraphy is useful in the diagnosis of occult rib fractures66; however, there is inconsistent interpretation in children younger than 18 months of age. Bone scintigraphy is not useful for areas that are normally active such as the physis and metaphysis, but is very good when imaging areas away from the physis, such as the shaft of a long bone. Scintigraphy is not reliable to detect skull fractures.196 Bone scan and skeletal survey may be considered complementary rather than competing imaging modalities; however, the skeletal survey is performed first. Jaudes128 found that when results of either a bone scan or a skeletal survey were normal in a known abused child, the use of both tests often revealed additional occult fractures. Technetium scans are not useful for dating fractures because increased isotope uptake may occur at a fracture as early as 24 hours after injury and scan abnormalities may persist for years.92 
Follow-up skeletal survey at 2 weeks increases the diagnosis of occult fractures, because some fractures, especially of the ribs, may not be seen until callus appears at 10 to 14 days. Oblique thoracic films obtained on 2-week follow-up skeletal survey increased diagnostic yield, with 46% of repeat surveys revealing additional fractures.156,284 The second look skeletal survey better defines the fracture seen on the original survey and may help determine the age of the fracture.142 Kleinman et al.156 reported that a follow-up skeletal survey 2 weeks after the initial series detected 27% more fractures and provided assistance in dating 20% of previously detected fractures. In an effort to decrease radiation dose, a limited 15-view follow-up survey that excludes views of the skull and coned views of the joints has proven to be adequate to gain the necessary follow-up information.107 Fractures or questionable fractures diagnosed on the initial screening skeletal survey should be reimaged on the follow-up survey. Almost 10% of children who sustained suspected abuse have a normal initial skeletal survey, but have significant findings on a 2-week follow-up survey, suggesting that all potential victims should have a repeat skeletal survey.32 
The sensitivity of skeletal surveys diminishes in patients older than 2 years of age. They have less value for children older than age 5 years because the older child can describe where the pain is located. For children between the ages of 2 and 5 years, the test should be individualized.12 The cost-effectiveness of skeletal surveys in the older child appears to be low, but may be helpful for the child with a disability who cannot cooperate with the physical examination. In one study of 331 children, only eight patients without overt physical signs of child abuse had occult fractures revealed by the survey85; however, the use of the skeletal survey in these few patients possibly prevented both reinjury and death. Digital radiography through picture archiving and communication system has replaced standard film-screen imaging in most hospitals and is comparable to high-detail film-screen imaging.157,283 High-quality images with excellent image detail and spatial resolution are required to diagnose subtle skeletal abnormalities. The image acquisition and display parameters should be optimized for high diagnostic performance. Skeletal surveys should be supervised by a radiologist to ensure diagnostic quality. 

Dating Fractures

Radiographic proof of unexplained fractures in various stages of healing is believed to be strong evidence of child abuse (Fig. 9-8).3 The orthopedist often is asked to determine the age of fractures with some certainty to corroborate a history of injury given by caretakers. Experienced orthopedists and radiologists can roughly estimate the age range of fractures by their radiographic appearance and their experience reading many radiographs of known dated injuries. Although specific guidelines have been established for estimating the age of fractures in children,78 there is limited evidence-based data for accurately predicting the age of healing fractures.221 By studying healing clavicle fractures in newborns, Walters et al. concluded that subperiosteal new bone formation was present at 8 to 10 days and callus was present by 10 to 16 days. This can be used as a guide in dating fractures in cases of abuse. CMLs are acute until periosteal reaction appears at about 14 days; however, not all CML develop visible callus, so dating in the absence of callus should be done with caution.273 Skull fractures generally cannot be dated. 
Figure 9-8
Rib fractures in multiple stages of healing in a 4-month-old female victim of nonaccidental injury.
 
Frontal chest radiograph reveals acute (no periosteal reaction or healing) and subacute/healing (positive periosteal reaction) rib fractures (arrows).
Frontal chest radiograph reveals acute (no periosteal reaction or healing) and subacute/healing (positive periosteal reaction) rib fractures (arrows).
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Figure 9-8
Rib fractures in multiple stages of healing in a 4-month-old female victim of nonaccidental injury.
Frontal chest radiograph reveals acute (no periosteal reaction or healing) and subacute/healing (positive periosteal reaction) rib fractures (arrows).
Frontal chest radiograph reveals acute (no periosteal reaction or healing) and subacute/healing (positive periosteal reaction) rib fractures (arrows).
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In a review of studies that met minimal evidence-based inclusion criteria, the following conclusions were reached: The science of fracture dating is inexact and periosteal reaction is seen as early as 4 days and is present in at least 50% of cases by 2 weeks with remodeling peaking at 8 weeks after the fracture. The most difficult fractures to date are those that are completely healed, with substantial remodeling, and often the only sign of a healed fracture is a thickened cortex. 

Skull Fractures

Infants in the first year of life with fractures of the skull or the extremities have an equal risk of the etiology being either accident or abuse.188 However, 80% of skull fractures from abuse are seen in infants less than 1 year of age. Skull fractures were the most commonly reported fracture in one series.190 Detailed postmortem analysis of 31 abused infants, with an average age of 3 months, observed confirmed skull fractures in 13.154 Skeletal surveys missed 26% of skull fractures confirmed on CT scan.229 Skull fractures are nonspecific and the morphology of the fracture does not distinguish accidental from inflicted trauma.23 Simple linear skull fractures are usually accidental; however, 80% of inflicted skull fractures are also linear.176 Complex skull fractures without a history of significant trauma, including comminuted, diastatic (separated sutures), displaced fractures, and fractures crossing suture lines, are suspicious, but not diagnostic for abuse.39 Skull fractures cannot be dated. 

Extremity Fractures

There is no predominant pattern of diaphyseal fracture in child abuse. Traditionally, a midshaft spiral fracture such as in the femur was believed to be caused by a violent abusive twisting injury. However, this is not typically the case. In a study of 23 long-bone fractures in abused children, spiral fractures were found in 78%.115 However, others found that 71% of diaphyseal fractures were transverse in abused children.96 Loder and Bookout181 reviewed 69 long-bone fractures in abused children and noted that 56% were transverse, 36% oblique, and only 8% spiral. In another study of 429 fractures,86 48% of fractures were transverse and 26% were spiral. Most of these long-bone fractures were in either the middle or distal third of the shaft. Transverse fractures are most commonly associated with either a violent bending force or a direct blow to the extremities, whereas spiral or oblique fractures of the long bones are caused by axial-loaded, twisting injuries, such as in a fall. Humeral shaft fractures in children under 3 years of age have an 18% risk of being because of probable abuse.234 In delayed medical care, long-bone fractures may show exuberant callus because of lack of immobilization, and multiple fractures may be present in different stages of healing.6 Juxtacortical calcification may be seen without fracture when there is diaphyseal periosteal separation resulting from tractional or torsional force when the limb is grasped or pulled along the shaft of the bone.195 
Femur fractures in infants are especially suspicious for NAT; whereas children old enough to run can fall and accidentally fracture their femurs if there is a significant twisting motion at the time of injury.264 Despite a high likelihood of NAT in an infant with a femoral fracture, an infant with a femur fracture may have accidental trauma as the cause, if the parent's reported mechanism is consistent with the injury. In a recent case series from Alberta, Canada, only 17% of femoral fractures in infants less than 1 year of age were from abuse, whereas the author's review of eight previous reports showed that NAT was the cause for 42% to 93% of cases.122 As children get older and more active, a femur fracture is more likely to be from accidental injury than from abuse. Schwend et al.233 reported that while 42% of femoral fractures in infants not walking were related to NAI, only 2.6% of femoral fractures in ambulatory toddlers were related to NAI. Blakemore et al.38 noted that only 2% of femoral fractures from age 1 to 5 years were caused by abuse. Risk factors for abuse were age younger than 12 months, the child not yet walking, a questionable mechanism, and other associated injuries. 
Humeral shaft fractures are frequently seen in NAT (Fig. 9-9). Fractures in unusual locations such as the distal clavicle, scapula, acromial tip, proximal humeral metaphysis, or distal humeral physis may result from violent blows or upper extremity traction injury and are suggestive of abuse in young children.10 Infants may normally have a separate ossification center adjacent to the tip of the acromion, simulating a fracture,160 but a true fracture has sharp, demarcated edges, may be positive on bone scan, and will show callus or healing. Although Kleinman148 described fractures of the sternum to be specific for child abuse, accidental midsternal fractures in children have been reported.109 
Figure 9-9
Humeral fracture in a 3-week-old male after a difficult delivery.
 
Radiograph shows a transverse mid diaphyseal fracture with extensive callus (arrow).
Radiograph shows a transverse mid diaphyseal fracture with extensive callus (arrow).
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Figure 9-9
Humeral fracture in a 3-week-old male after a difficult delivery.
Radiograph shows a transverse mid diaphyseal fracture with extensive callus (arrow).
Radiograph shows a transverse mid diaphyseal fracture with extensive callus (arrow).
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Fractures of the hands and feet are commonly because of accidental trauma in older children,196 but are suspicious for abuse in infants. Nimkin et al.203 reviewed 11 hand and foot fractures in abused children younger than 10 months of age and found mostly torus fractures either of the metacarpals or the proximal phalanges of the hand and similar fractures of the first metatarsals of the feet (Fig. 9-10). Clinical signs of fracture were present in only one patient, and bone scans were insensitive to the presence of the fractures in all patients. These injuries are best seen on the oblique views standard in the skeletal survey. 
Figure 9-10
Metatarsal fractures in a 2-month-old female victim of nonaccidental trauma.
 
Radiographic image from a skeletal survey shows multiple healing, bilateral, and symmetric proximal and distal metatarsal fractures (arrows).
Radiographic image from a skeletal survey shows multiple healing, bilateral, and symmetric proximal and distal metatarsal fractures (arrows).
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Figure 9-10
Metatarsal fractures in a 2-month-old female victim of nonaccidental trauma.
Radiographic image from a skeletal survey shows multiple healing, bilateral, and symmetric proximal and distal metatarsal fractures (arrows).
Radiographic image from a skeletal survey shows multiple healing, bilateral, and symmetric proximal and distal metatarsal fractures (arrows).
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Metaphyseal and epiphyseal fractures of the long bones are classically associated with child abuse.45,240 In infants and toddlers, these fractures can occur when the child is violently shaken by the extremities with direct violent traction or rotation of the extremity (Fig. 9-9).196 Buckle fractures may occur at multiple sites, seldom producing exuberant callus. Repeated injury may cause irregular metaphyseal deformities. Periosteal avulsion typically produces new bone formation within 2 to 3 weeks of injury and may be confused with osteomyelitis.6 New bone formation may be delayed, particularly in children with malnutrition or rickets. Metaphyseal fractures constituted 40% of fractures in one series,96 but fewer than 15% in another.163 
Kleinman148 ranked the specificity of skeletal trauma for abuse (Table 9-9). Distinguishing between an accident and child abuse is based on the location and the type of fracture. He emphasized that both moderate- and low-specificity radiographic findings of child abuse become much more specific when there is an inadequate explanation for the injury. The presence of multiple injuries, particularly in the young child, is especially concerning for abuse. 
Compared to healthy term infants, premature infants are more susceptible to fractures, both related to their prematurity and increased risk of child abuse.51 They may have underlying genetic, metabolic, and nutritional deficiency that predispose to fractures. Underlying osteopenia may lead to insufficiency fractures, both acute and chronic, in various stages of healing. Higher parental stress from caring for a sick or disabled infant may result in higher risk of NAT. In the premature infant with multiple fractures, investigation of the bone health as well as for child abuse is necessary, depending on the clinical context and findings. 

Classic Metaphyseal Lesion of Child Abuse

The almost pathognomonic fracture of child abuse is the CML, commonly termed the “corner” or “bucket-handle fracture.”6 These fractures are almost exclusively seen in NAI, but are not the most common fractures in abused children. The incidence of CML in large series ranges from 15% to 32%.96,147,163,181 Radiographs show a corner fracture at the edge of the ossified portion of the zone of provisional calcification, which is the metaphyseal side of the physis as opposed to the epiphyseal side. If a significant portion of the metaphyseal rim is involved, a bucket-handle fracture pattern is produced. Based on their histopathologic autopsy study of metaphyseal fractures in abused infants, Kleinman et al.151,153 found that bucket-handle or corner fractures are actually a full-thickness metaphyseal fracture extending through the primary spongiosa of bone just above the zone of provisional calcification (Fig. 9-11). Centrally, the amount of metaphysis remaining attached to the physis was thin, but peripherally the fracture line curved away from the physis so that a substantial metaphyseal rim remained attached to the physis (Fig. 9-12). On radiographic study, this metaphyseal rim formed the basis for both corner and bucket-handle fractures. In healing fractures, biopsy specimens showed metaphyseal extension of hypertrophied chondrocytes.210 Metaphyseal corner fractures are most likely caused by either violent shaking or traction injuries to the extremity.4 Even one CML noted on a skeletal survey is highly suspicious and specific for child abuse.158 Subepiphyseal–metaphyseal lucency can also be caused by systematic disease such as rickets and leukemia. Lesions resembling corner fractures of the distal radius, ulna, tibia, and proximal humerus also have been reported with one variant of spondylometaphyseal dysplasia.72 Because fracture callus does not reliably occur, dating the CML lesion is always unreliable. The presence of callus does indicate that the fracture is probably greater than 10 to 14 days. 
Figure 9-11
Schematic representation of classic metaphyseal lesions (CMLs).
 
Illustration demonstrates the path of the CML. Depending upon the angle at which the CML is viewed from, it may appear to extend across the width of the ossified physis (tibia illustrating a bucket-handle fracture) or only the margins of the physis (femur, illustrating a corner fracture).
 
(Artwork courtesy of Gholamreza Zinati, MD.)
Illustration demonstrates the path of the CML. Depending upon the angle at which the CML is viewed from, it may appear to extend across the width of the ossified physis (tibia illustrating a bucket-handle fracture) or only the margins of the physis (femur, illustrating a corner fracture).
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Figure 9-11
Schematic representation of classic metaphyseal lesions (CMLs).
Illustration demonstrates the path of the CML. Depending upon the angle at which the CML is viewed from, it may appear to extend across the width of the ossified physis (tibia illustrating a bucket-handle fracture) or only the margins of the physis (femur, illustrating a corner fracture).
(Artwork courtesy of Gholamreza Zinati, MD.)
Illustration demonstrates the path of the CML. Depending upon the angle at which the CML is viewed from, it may appear to extend across the width of the ossified physis (tibia illustrating a bucket-handle fracture) or only the margins of the physis (femur, illustrating a corner fracture).
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Figure 9-12
Classic metaphyseal fracture in a 2.5-month-old male victim of nonaccidental injury.
 
A: Frontal radiograph of the tibia and fibula demonstrates transmetaphyseal lucencies or bucket-handle fractures (arrows). B: A lateral ankle radiograph reveals lucency at the tibial and fibular metaphyseal margins indicating corner fractures (arrows).
A: Frontal radiograph of the tibia and fibula demonstrates transmetaphyseal lucencies or bucket-handle fractures (arrows). B: A lateral ankle radiograph reveals lucency at the tibial and fibular metaphyseal margins indicating corner fractures (arrows).
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Figure 9-12
Classic metaphyseal fracture in a 2.5-month-old male victim of nonaccidental injury.
A: Frontal radiograph of the tibia and fibula demonstrates transmetaphyseal lucencies or bucket-handle fractures (arrows). B: A lateral ankle radiograph reveals lucency at the tibial and fibular metaphyseal margins indicating corner fractures (arrows).
A: Frontal radiograph of the tibia and fibula demonstrates transmetaphyseal lucencies or bucket-handle fractures (arrows). B: A lateral ankle radiograph reveals lucency at the tibial and fibular metaphyseal margins indicating corner fractures (arrows).
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Rib Fractures

Rib fractures are uncommon in childhood accidents, especially when located posterior and associated with other long-bone fractures. Although no single fracture is specific for abuse, rib fractures are highly suggestive of abuse if there is no plausible trauma or medical explanation.142 Abusive rib fractures may be caused by squeezing of the chest by a caretaker,45 hitting the child from behind, or stepping on the chest.156,244 Kleinman et al.155 postulated that severe shaking of an infant can cause front-to-back chest compression, which levers the posterior rib over the transverse process of the vertebral body, causing fractures of the posterior rib shaft at the transverse process and of the rib head adjacent to the vertebra (Fig. 9-13). One series showed that fractures of the first rib in children were only seen in abuse.253 Barsness et al.26 reported that rib fractures had a positive predictive value of NAI of 95% in children younger than 3 years of age. In this study, rib fracture(s) were the only skeletal manifestation of NAI in 29% of the children. Posterior rib fractures are difficult to diagnose acutely because they lack callus and are rarely displaced. Even with healing, the callus on radiography may be obscured by the overlying transverse process.152 Oblique views of the chest are included in skeletal surveys because they better show these fractures. Posterior rib fractures are the most common location in child abuse, but fractures may occur anywhere along the arc of the rib, including disruption of the anterior costochondral junction (Fig. 9-14). Posterior rib fractures tend to occur between T4 and T9. Acute anterior costochondral separations of the ribs may be difficult to see on chest radiographs,243 and with healing, the anterior end of the osseous rib becomes widened and club shaped.163,207 Anterior rib fractures are commonly associated with abdominal injury and can be detected on CT scan. Healing fractures show callus, but healed fractures may be subtle, with only a fusiform thickening of the rib. Older fractures of the ribs in NAT may form lytic, expansile lesions.183 
Figure 9-13
Schematic representation of rib fracture mechanism.
 
Anterior chest compression causes the posterior ribs to be levered over the transverse processes of the vertebra (arrows) causing posterior and lateral rib fractures (arrowheads).
 
(Artwork courtesy of Samir Abedin, MD.)
Anterior chest compression causes the posterior ribs to be levered over the transverse processes of the vertebra (arrows) causing posterior and lateral rib fractures (arrowheads).
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Figure 9-13
Schematic representation of rib fracture mechanism.
Anterior chest compression causes the posterior ribs to be levered over the transverse processes of the vertebra (arrows) causing posterior and lateral rib fractures (arrowheads).
(Artwork courtesy of Samir Abedin, MD.)
Anterior chest compression causes the posterior ribs to be levered over the transverse processes of the vertebra (arrows) causing posterior and lateral rib fractures (arrowheads).
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Figure 9-14
Rib fractures in a 9-month-old male victim of nonaccidental trauma.
 
A: Chest radiograph reveals left lateral sixth and seventh rib fractures (arrows). B: Nuclear medicine bone scan confirms foci of increased uptake within the left lateral ribs as well as revealing additional hot foci in multiple right posterior lateral ribs.
A: Chest radiograph reveals left lateral sixth and seventh rib fractures (arrows). B: Nuclear medicine bone scan confirms foci of increased uptake within the left lateral ribs as well as revealing additional hot foci in multiple right posterior lateral ribs.
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Figure 9-14
Rib fractures in a 9-month-old male victim of nonaccidental trauma.
A: Chest radiograph reveals left lateral sixth and seventh rib fractures (arrows). B: Nuclear medicine bone scan confirms foci of increased uptake within the left lateral ribs as well as revealing additional hot foci in multiple right posterior lateral ribs.
A: Chest radiograph reveals left lateral sixth and seventh rib fractures (arrows). B: Nuclear medicine bone scan confirms foci of increased uptake within the left lateral ribs as well as revealing additional hot foci in multiple right posterior lateral ribs.
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Rib fractures are rarely discovered in abused infants who have undergone resuscitation for cardiac arrest; in which case, there may be confusion about the etiology of the fractures. However, the elasticity of the infant chest allows a high tolerance to compression, having low reported rates of rib fractures from cardiopulmonary resuscitation between 0.3% and 2%, with none being posterior rib fractures.184 Cardiopulmonary resuscitation is therefore a very rare cause of rib fractures and seldom causes classic posterior rib fractures. Death from cardiac arrhythmia from a blow to the chest has been reported in a 7-week-old abused infant whose rib fractures at autopsy were initially thought to be caused by resuscitation efforts.19 In addition to rib fractures, abused infants can sustain severe lung contusion and respiratory distress from chest wall trauma,189 with fatal fat embolus reported.202 Chest physiotherapy for infants with respiratory infection is a very rare cause of multiple rib fractures, about 1 in 1000 infants receiving this treatment.57 
In infant fatalities of suspicious origin, postmortem high-detailed preautopsy skeletal surveys and specimen radiographs are helpful in fully evaluating and diagnosing child abuse.149 In a postmortem study of 31 infants who died of inflicted skeletal injury,154 there were a total of 165 fractures (51% rib fractures, 39% metaphyseal long-bone fractures, 5% long-bone shaft fractures, 4% fractures of the hands and feet, 1% clavicular fractures, and less than 1% spinal fractures). Postmortem thoracic CT is more sensitive than radiography for pediatric anterior and posterior rib fractures.118 If an abdominal CT is being performed for evaluation of NAT, inclusion of the chest may yield additional information about rib fractures, but at a cost of additional radiation of approximately 3 mSv. 

Spinal Fractures

Spinal fractures in abused children are infrequent but important to recognize. Based on autopsy findings,150 spinal fractures of fatally abused children generally involve 25% or less compression of the vertebrae. In a report of 103 children with cervical spine injury, only three patients had injury because of abuse and all had SCIWORA.42 In another study of fractures of the cervical spine, prevertebral soft tissue edema on radiographs was the only sign of cervical injury, because spontaneous reduction of the cervical vertebrae after dislocation was common.223 Thomas et al.263 reported a 9-week-old boy with spinal cord injury resulting from cervical spine fracture who presented as a floppy infant. Although routine cervical radiographs were normal, MRI studies showed retropulsion of a fragment of the primarily cartilaginous C3 vertebrae into the spinal canal. Hangman's type fractures of the posterior elements have been described in infants as a result of child abuse.159 This must be distinguished from C2 primary spondylolysis which may be associated with pyknodysostosis, both of which are rare disorders associated with wormian bones and pencil pointing of the distal phalanges.71 
CT is helpful in evaluating pediatric cervical trauma. Rooks et al.226 reported a compression fracture of C5 with anterior subluxation of C4 on C5 in a 3-month-old abused premature twin requiring decompression and cervical fusion. The other twin had a C5 on C6 fracture subluxation treated with casting, but later required surgery to reduce and fuse the subluxation. MRI was very helpful in showing spinal cord compression in both cases. Oral et al.208 reported on an inflicted avulsion fracture of C2 and interspinous ligament injury in a 4-year-old child. 
Vertebral compression fractures can occur when a child's buttocks are forcibly slammed onto a flat surface with hyperflexion of the spine.5,47 Half of these fractures involved the anterosuperior end plate associated with a compression deformity, 30% had pure compression fractures, and 20% had fractures of the superior end plate without significant compression. Positioning premature infants in extreme hyperflexion for lumbar puncture has been reported to cause iatrogenic lumbar spine fracture.101 Carrion et al.50 reported circumferential physeal fractures of the thoracolumbar spine associated with child abuse that required open reduction. Thoracolumbar fracture dislocations may occur in abused children with or without neurologic injury.177,237 Flexion–distraction Chance fractures and synchondroses injuries (Fig. 9-15) may also be seen in NAT. Although neurologic injury in spinal fractures resulting from child abuse is uncommon,70 any patient with abusive spinal injury should undergo thorough neurologic examination (Fig. 9-15). Skeletal survey must include a lateral view of the cervical, thoracic, and lumbar spine. Because of the potentially serious consequences of a spinal injury in an infant or young child, clinical or radiographic suggestion of a spinal injury should be further evaluated with MRI. If a patient has evidence of AHT to require MRI, it should include the entire spine.144 
Figure 9-15
Lumbar spine fracture in a 16-month-old male victim of nonaccidental trauma.
 
A: Lateral lumbar radiograph shows lucency through the L3 synchondrosis (arrow) with anterolisthesis of L3 body on L4. B: Sagittal T2-weighted MRI reveals hyperintense signal within the bone marrow of the fractured L3. Slight compression fractures of T10 and T11 are also noted (arrows).
A: Lateral lumbar radiograph shows lucency through the L3 synchondrosis (arrow) with anterolisthesis of L3 body on L4. B: Sagittal T2-weighted MRI reveals hyperintense signal within the bone marrow of the fractured L3. Slight compression fractures of T10 and T11 are also noted (arrows).
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Figure 9-15
Lumbar spine fracture in a 16-month-old male victim of nonaccidental trauma.
A: Lateral lumbar radiograph shows lucency through the L3 synchondrosis (arrow) with anterolisthesis of L3 body on L4. B: Sagittal T2-weighted MRI reveals hyperintense signal within the bone marrow of the fractured L3. Slight compression fractures of T10 and T11 are also noted (arrows).
A: Lateral lumbar radiograph shows lucency through the L3 synchondrosis (arrow) with anterolisthesis of L3 body on L4. B: Sagittal T2-weighted MRI reveals hyperintense signal within the bone marrow of the fractured L3. Slight compression fractures of T10 and T11 are also noted (arrows).
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Laboratory Studies

An abused child should have a complete blood cell count with sedimentation rate, liver function studies, and urinalysis. Clotting studies, including prothrombin time and activated partial thromboplastin time, thrombin time, fibrinogen, factor VIII, factor IX, and von Willebrand factor antigen and activity should be performed in patients with bleeding or ecchymosis to evaluate for bleeding diathesis. If bruising is the only finding of possible abuse, consultation with a hematologist may be necessary to fully evaluate for an unusual bleeding disorder.262 Infants born prematurely are at risk for rickets and low bone density. Therefore, evaluation of calcium, phosphorous, alkaline phosphatase, and 25-OH vitamin D may be useful in such infants. 
Recently, two biomarkers for head injury, neuron-specific enolase S100B and myelin-basic protein, have been found to be released into the peripheral circulation, analogous to cardiac enzyme release after myocardial injury. These two markers when used together are 79% sensitive and 100% specific in diagnosing traumatic brain injury, making them potentially very promising for evaluating suspected mild head trauma.34 If there is suspicion of substance abuse by any family member, a toxicology screen should also be performed on the patient.96 

Multidisciplinary Approach

The most important consultation to request for a child with suspected inflicted injury is the child protective services team. In a study by Banaszkiewicz et al.,20 three tiers of physicians reviewed the medical records of 74 children under the age of 1 year presenting to the emergency department with fractures: Staff clinicians, orthopedic attendings, and a child protective team pediatrician. In over one-fourth of cases of abuse, the possibility was underestimated during the original evaluation. Any suspected abuse should initiate a minimum evaluation that includes an appropriate radiographic evaluation with a skeletal survey in the younger child, dilated fundoscopic examination by an ophthalmologist, and consultation by a child abuse specialist. Any significant nonorthopedic injury should prompt consultation by the appropriate subspecialty: Neurosurgery, general surgery, plastic surgery, ophthalmology, or urology.6 In cases of suspected sexual abuse, a thorough genital examination will be required, including a gynecologic consultation for girls. This is typically initiated by the child protective services team. 

The Differential Diagnosis

Although it is extremely important not to miss the diagnosis of child abuse, it is equally important to maintain an objective, critical view and not to make the diagnosis in error.129 Overdiagnosing child abuse can be harmful to the family, with the parents being placed at risk of losing custody of their children and also facing criminal charges.138 Even direct allegations of child abuse may turn out to be false. Patients or family friends may make false statements about an abuse situation through misinterpretation, confabulation, fantasy, delusions, and other situations.35 The American Academy of Child and Adolescent Psychiatry9 has published guidelines for the evaluation of abuse, stating that the possibility of false allegations needs to be considered, particularly if the charges are coming from the parent rather than the child, the parents are engaged in a dispute over custody or visitation, or the child is a preschooler. 
Normal metaphyseal variations are seen occasionally and should not be confused with corner fractures of child abuse. These variants are seen most commonly in the proximal tibia, distal femur, proximal fibula, distal radius, and distal ulna. A bony beak may be seen medially in the proximal humerus or tibia, and is usually bilateral. Cortical irregularity in the medial proximal tibia may also be seen in 4% of normal infants and young toddlers and is bilateral in 25%. Beaks may extend beyond the metaphyseal margins in both the distal radius and the lateral aspect of the distal femur, with bilateral normal variants in 25% of infants and young toddlers.205 
The signs of child abuse found on radiographs can overlap with the findings of systemic diseases such as Caffey disease (infantile cortical hyperostosis), osteomyelitis, septic arthritis, insufficiency fracture, hypophosphatasia (Fig. 9-16), leukemia (Fig. 9-17), metastatic neuroblastoma, OI (Fig. 9-18), scurvy (Fig. 9-19), vitamin D deficient and drug-induced rickets (Fig. 9-20), congenital insensitivity to pain, osteopetrosis, kinky hair syndrome, prostaglandin therapy, osteoid osteoma, and other benign bone tumors.6 Children with biliary atresia may present with osteopenia and fractures without history of significant injury, which should not be mistaken for child abuse.75 There has been an increase in the incidence of syphilis in females of childbearing age, and, although extremely rare, congenital syphilis can mimic fractures of child abuse with diaphysitis, metaphysitis, and multiple pathologic fractures in different stages of healing.178 Physiologic periostitis, in contrast to lesions from child abuse, is seen in young infants of about 6 months of age, is usually bilateral, symmetric, diaphyseal, located on the long bones – humerus, femur, and tibia – and has no periostitis of the metaphysis.66 Insufficiency rib fractures may be seen in rickets of prematurity as well as rickets of low birth weight and also have been reported after chest physiotherapy.56 The presence of metabolic disease and pathologic fractures does not exclude the possibility of child abuse. Duncan and Chandy84 reported a 3-month-old girl with multiple fractures associated with rickets who died suddenly at 5 months of age. Child abuse was suspected but not proven. Three years later, evidence of child abuse was found in a subsequent sibling in the same family. 
Figure 9-16
Hypophosphatasia in a 2-month-old female with multiple fractures.
 
A: Chest radiograph shows severe osteopenia and multiple bilateral healing rib fractures. B: Lateral spine radiograph reveals multiple compressed vertebra. C: Lower extremity radiographs demonstrate multiple, bilateral healing femoral and lower leg fractures.
A: Chest radiograph shows severe osteopenia and multiple bilateral healing rib fractures. B: Lateral spine radiograph reveals multiple compressed vertebra. C: Lower extremity radiographs demonstrate multiple, bilateral healing femoral and lower leg fractures.
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A: Chest radiograph shows severe osteopenia and multiple bilateral healing rib fractures. B: Lateral spine radiograph reveals multiple compressed vertebra. C: Lower extremity radiographs demonstrate multiple, bilateral healing femoral and lower leg fractures.
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Figure 9-16
Hypophosphatasia in a 2-month-old female with multiple fractures.
A: Chest radiograph shows severe osteopenia and multiple bilateral healing rib fractures. B: Lateral spine radiograph reveals multiple compressed vertebra. C: Lower extremity radiographs demonstrate multiple, bilateral healing femoral and lower leg fractures.
A: Chest radiograph shows severe osteopenia and multiple bilateral healing rib fractures. B: Lateral spine radiograph reveals multiple compressed vertebra. C: Lower extremity radiographs demonstrate multiple, bilateral healing femoral and lower leg fractures.
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A: Chest radiograph shows severe osteopenia and multiple bilateral healing rib fractures. B: Lateral spine radiograph reveals multiple compressed vertebra. C: Lower extremity radiographs demonstrate multiple, bilateral healing femoral and lower leg fractures.
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Figure 9-17
Leukemia in a 4-year-old boy presenting with back pain.
 
Lateral spine radiograph shows osteopenia and multiple spine compression fractures.
Lateral spine radiograph shows osteopenia and multiple spine compression fractures.
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Figure 9-17
Leukemia in a 4-year-old boy presenting with back pain.
Lateral spine radiograph shows osteopenia and multiple spine compression fractures.
Lateral spine radiograph shows osteopenia and multiple spine compression fractures.
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Figure 9-18
Osteogenesis imperfecta in a 2-month-old female with multiple rib and extremity fractures.
 
Frontal radiograph of the chest and abdomen reveals diffuse osteopenia as well as multiple bilateral rib and proximal extremity fractures in various stages of healing.
Frontal radiograph of the chest and abdomen reveals diffuse osteopenia as well as multiple bilateral rib and proximal extremity fractures in various stages of healing.
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Figure 9-18
Osteogenesis imperfecta in a 2-month-old female with multiple rib and extremity fractures.
Frontal radiograph of the chest and abdomen reveals diffuse osteopenia as well as multiple bilateral rib and proximal extremity fractures in various stages of healing.
Frontal radiograph of the chest and abdomen reveals diffuse osteopenia as well as multiple bilateral rib and proximal extremity fractures in various stages of healing.
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Figure 9-19
 
Scurvy in a 3-year-old male with bruising and petechia (A), bleeding and infected appearing gums, poorly healing biopsy incision (B), and bilateral distal femoral fractures. C: Lateral radiographs of the lower extremities show bilateral subperiosteal hematomas seen as uplifting of the periosteum (arrows). D: Follow-up frontal radiograph of the lower extremities after treatment with vitamin C demonstrates calcification of subperiosteal hematomas, as well as metaphyseal irregularity similar to classic metaphyseal lesions (arrowheads).
Scurvy in a 3-year-old male with bruising and petechia (A), bleeding and infected appearing gums, poorly healing biopsy incision (B), and bilateral distal femoral fractures. C: Lateral radiographs of the lower extremities show bilateral subperiosteal hematomas seen as uplifting of the periosteum (arrows). D: Follow-up frontal radiograph of the lower extremities after treatment with vitamin C demonstrates calcification of subperiosteal hematomas, as well as metaphyseal irregularity similar to classic metaphyseal lesions (arrowheads).
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Figure 9-19
Scurvy in a 3-year-old male with bruising and petechia (A), bleeding and infected appearing gums, poorly healing biopsy incision (B), and bilateral distal femoral fractures. C: Lateral radiographs of the lower extremities show bilateral subperiosteal hematomas seen as uplifting of the periosteum (arrows). D: Follow-up frontal radiograph of the lower extremities after treatment with vitamin C demonstrates calcification of subperiosteal hematomas, as well as metaphyseal irregularity similar to classic metaphyseal lesions (arrowheads).
Scurvy in a 3-year-old male with bruising and petechia (A), bleeding and infected appearing gums, poorly healing biopsy incision (B), and bilateral distal femoral fractures. C: Lateral radiographs of the lower extremities show bilateral subperiosteal hematomas seen as uplifting of the periosteum (arrows). D: Follow-up frontal radiograph of the lower extremities after treatment with vitamin C demonstrates calcification of subperiosteal hematomas, as well as metaphyseal irregularity similar to classic metaphyseal lesions (arrowheads).
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Figure 9-20
Rickets in a 16-month-old male who was breast-fed.
 
A: Lateral forearm radiograph shows osteopenia and a distal radial fracture (arrow) with some dorsal angulation (B, C). Metaphyseal cupping and fraying of the distal radius and ulna bilaterally are also noted.
A: Lateral forearm radiograph shows osteopenia and a distal radial fracture (arrow) with some dorsal angulation (B, C). Metaphyseal cupping and fraying of the distal radius and ulna bilaterally are also noted.
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Figure 9-20
Rickets in a 16-month-old male who was breast-fed.
A: Lateral forearm radiograph shows osteopenia and a distal radial fracture (arrow) with some dorsal angulation (B, C). Metaphyseal cupping and fraying of the distal radius and ulna bilaterally are also noted.
A: Lateral forearm radiograph shows osteopenia and a distal radial fracture (arrow) with some dorsal angulation (B, C). Metaphyseal cupping and fraying of the distal radius and ulna bilaterally are also noted.
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Several diseases are commonly brought up in custodial hearings as alternative possibilities to nonaccidental traumatic injuries, and these diseases should be objectively considered in the differential diagnosis. Linear lucencies of the proximal tibia noted after intraosseous vascular access needles may mimic fractures, but careful analysis of the imaging studies can determine the actual cause of the lucency.108 Metaphyseal corner fractures of the distal tibia and fibula were seen in eight children treated with likely forceful serial casting for clubfoot, with only one potentially related to NAT.99 Leukemia should always be considered in a child with diffuse osteopenia or metaphyseal lucencies. McClain et al.187 reported a 2-year-old child who died of undiagnosed acute lymphoblastic leukemia, having been earlier reported as a possible victim of child abuse. Ecchymosis on the back and extremities did not initiate an appropriate evaluation for leukemia or bleeding disorder. Clinical signs of leukemia, including fever, pallor, petechia, purpura, adenopathy, hepatosplenomegaly, and bone pain, should be sought in children with bruising of unknown origin. Factor XIII deficiency may cause unexplained bleeding from minor trauma and be mistaken for child abuse because the standard coagulation profile may be negative and factor-specific tests may be negative if performed post transfusion.200 

Osteogenesis Imperfecta

Undiagnosed OI should always be considered when a child presents with multiple fractures of unknown etiology, but may be a difficult diagnosis to make.229 Before the diagnosis of OI is made the parents may be presumed to be the cause of the fractures, with temporary removal of a child in 70% of cases.162 OI caused by spontaneous mutation can occur without a family history.215 The so-called hallmark of OI is an intensely blue sclerae, but this feature is consistently present only in Sillence type I,238 may be completely absent in patients with type IV, and is less obvious in type III.215 Sillence et al.239 noted that patients with either type II or III OI may have blue sclerae at birth, but the sclerae can become normal by adolescence. The rare Sillence type II OI, termed Congenta A in the Shapiro classification, has normal sclerae, but bone abnormalities and osteopenia are severe and early death is likely.215 Blue sclerae may be present in normal young infants and can be misinterpreted as a sign of OI. The presence of abnormal teeth, known as dentinogenesis imperfecta, may be helpful in a diagnosis if the child is old enough for teeth to have erupted. Plain radiographs may show long bones of normal density in both types I and IV OI. Another radiographic sign of OI, wormian bones of the skull, is consistently present only in type III and is often absent in types I and IV.215 Because type IV OI does not have blue sclera or wormian bones and is a milder form of OI than type III, diagnosis may be initially delayed or confused with NAT. Other rare types of OI have been described, which further confounds the medical and legal evaluation. Some authors believe that the presence of metaphyseal fracture is pathognomonic for child abuse and, therefore, helpful to distinguish abuse from OI,1,15 but others74,215 believe that there is no particular fracture pattern that renders the diagnosis of OI likely. Children with OI tend to bruise excessively, which overlaps with child abuse.235 SIDS has also been described in infants with undiagnosed OI.205 
When the diagnosis of OI cannot be made on clinical grounds, the diagnosis may be made by biochemical assay. Gahagan and Rimsza95 reported that 87% of children with OI have abnormal procollagen that can be detected by a skin biopsy with fibroblast culture. Fibroblasts are assayed for abnormally low levels of procollagen as well as primary abnormal procollagen.44 Steiner et al.249 reported that over a 4-year period, 48 patients were referred for collagen analysis to diagnose OI in cases of suspected child abuse. Only 6 of these 48 children had abnormal collagen test results, and in five of the six patients, the diagnosis of OI could have been made on clinical and radiologic findings. More recently, Marlowe et al.185 found 11 of 262 samples submitted to rule out OI had alterations in the amount or structure of type I collagen synthesized, consistent with the diagnosis of OI. In 11 others, OI could not be excluded. Referring physicians correctly diagnosed children with OI in 6 of the 11 patients clinically. Four children believed to have OI by physical examination had normal biochemical studies, representing a false-positive clinical diagnosis, attributed mostly to the use of sclera hue as a major diagnostic criterion.186 The authors concluded that laboratory testing for OI remains a valuable adjunct when determining the etiology of fractures in children. Even when a child has OI or other metabolic bone disorders, fractures may be because of comorbid NAT. Knight and Bennett161 reported a young child with OI whose abuse could not be proved until linear bruising of the face from being slapped was documented. 

Temporary Brittle Bone Disease

In 1993, Paterson et al.215 described 39 patients with a variant of OI that they described as a temporary brittle bone disease in which fractures were limited to the first year of life followed by spontaneous improvement. However, an extensive review by the Society for Pediatric Radiology194 concluded that the entity of temporary brittle bone disease has insufficient scientific evidence to warrant this as a plausible diagnosis. This diagnosis as a plausible explanation for NAT with multiple fractures should be discouraged.131 

Sudden Unexpected Death in Infancy

The death of an infant is a sentinel event and must be handled appropriately with the medical and the legal systems cooperatively involved.133 SIDS is a subset of sudden unexpected death in infancy (SUDI) and refers to the death of an infant less than 1 year of age with the onset of the fatal episode apparently occurring during sleep that remains unexplained after a thorough review of the circumstances of death and clinical history.133,277,278 Because SIDS is more common than infanticide, death by abuse intentional suffocation is very commonly initially attributed to SIDS before the correct diagnosis is made.124 However, other causes of sudden death such as intracranial bleeds must be excluded. Byard et al.43 reported a 5-month-old girl who died suddenly from spontaneous subarachnoid hemorrhage from undiagnosed Ehlers–Danlos syndrome. They recommended collagen analysis in patients with unexplained multifocal spontaneous hemorrhages to exclude this rare syndrome. Sperry and Pfalzgraf246 reported a 9-month-old infant whose diagnosis of SIDS became uncertain when postmortem radiographs showed healing symmetric clavicle fractures and a healing left medial humeral condyle fracture. Subsequent investigation showed that the child had undergone “chiropractic” manipulation 4 weeks before death by an unlicensed therapist to correct “shoulder dislocations,” with the parents exonerated of abuse charges. When abuse is suspected in an infant fatality, combined radiology, CT scan, detailed forensic autopsy, and osteologic investigation are required to detect all fractures that are present.52 Detailed examination of organs, such as the orbit, is also becoming the standard in autopsy protocols.197 

Postemergency Room Treatment and Legal Reporting Requirements

Once NAT is recognized, the first step in treatment is hospital admission.199 This is therapeutic in that it places the child in a safe, protected environment, provides the opportunity for additional diagnostic workup, and, more importantly, investigation of the family's social situation by appropriate personnel. In tertiary centers, multidisciplinary teams often are available to evaluate and treat such children, but in other circumstances the orthopedist may be primarily responsible for coordinating both evaluation and treatment. Court custody may be required for children of uncooperative families who refuse admission, and hospitalization should be continued until a full investigation is completed by the appropriate child protective services and a safe disposition is established. In the United States, the physician is required by law to report all suspected abuse to appropriate child protective services or legal authorities. Although physicians have better reporting rates than most other professionals, 27% of injuries considered likely to be caused by abuse and 76% of injuries that were considered possibly related to child abuse were not reported.89 When the reporting is done in good faith, the physician has immunity against criminal or civil liability for these actions, but in only three states – Ohio, California, and Alabama – does this protection include absolute immunity.63 The distinction is critical. Absolute immunity means that the physician who reports suspected child abuse cannot ever be held for damages sought by families for allegedly inappropriate reports of child abuse or neglect. The granting of absolute immunity, even for physicians, is not encouraged by the American legal system because in theory it would protect individuals who make false reports of child abuse to harass families and would deprive the injured parties their legal right to seek damages for harmful actions. In contrast, physician immunity based on good faith reporting of suspected child abuse is contingent on the physician having a reasonable belief that abuse or neglect has occurred. Although in theory this protection seems to be quite adequate, recently there has been a dramatic rise in the number of lawsuits filed by families seeking damages for alleged, unfounded reports of child abuse and neglect. Although it is true that by the time these lawsuits are eventually resolved, physicians have almost never been held liable for good faith reports of child abuse, in a substantial number of these cases, the physicians first lost at trial level before eventually prevailing at appeal. Considerable expense, frustration, and loss of time can be experienced by the physician in defending against such allegations as the families and their attorneys pursue multiple forms of legal theories in court and attempt to evade the immunity provisions.63 On the other hand, the stakes for failure to report suspected child abuse are likely much higher, potentially exposing the physician to charges of malpractice.4 
All states require physicians to report not only cases of definitive child abuse or neglect but also cases when abuse is just suspected or is considered a possibility. Physicians have been held liable for damages for their negligence in failing to diagnose child abuse when the child subsequently was reinjured by further abuse, and, ironically, the parents also may be able to collect additional compensation for losses resulting from medical expenses. For families to be successful in these lawsuits, they must be able to prove that the failure to make the diagnosis of child abuse was negligent and that, had the diagnosis been made, steps would have been taken to protect the child from additional abuse. Although the probability of a physician being held liable under such circumstances is low, the amount of damages can be high if the family does prevail when the child has suffered permanent sequelae.63 
After admission, the orthopedist proceeds with care of the child's musculoskeletal injuries and facilitates various medical consultations. Recommendations for disposition of the child after completion of medical treatment may be a group decision through a multidisciplinary team or, more often, the decision of the primary physician, who may be the orthopedist. Final disposition choices may include return to the family, return to a family member who does not live in the child's home, or placement in a shelter or a foster home setting. The risk of reinjury and death is significant if the abused child is returned to the unsafe home, so the orthopedist must strongly support child protective services in custodial actions when it is believed that a child's injury truly occurred from abuse at home. Not only must the definitive diagnosis of child abuse be documented in the chart, but also a separate notarized affidavit may be necessary. Commonly, custodial actions by child protective services are reviewed in a court hearing in a matter of weeks, and the physician may be called to testify in the hearing. Criminal charges also may be brought against the perpetrator of the child abuse, and the physician likely also serves as a witness in these proceedings. 

The Orthopedic Surgeon's Legal Role in Nonaccidental Injury

The orthopedist fills a dual role in the courtroom in child abuse proceedings. First, he or she serves as a material witness whose testimony is confined to the physician's personal involvement in the legal matter of the child's evaluation and treatment. The testimony may include clarification to the court of information contained in the medical record. As a material witness, the physician cannot render opinions about the facts as stated during his or her testimony. In addition, however, the physician may also be sworn in as an expert witness.103 An expert witness is an individual considered by the court to have special knowledge and experience that qualifies him or her to render opinions about certain facts presented in the courtroom. The limits of the physician's expertise usually are defined by the attorneys in court before the testimony of the expert witness. 
Physicians may be reluctant to testify in court for many reasons. The courtroom is an unfamiliar setting for most physicians and the adversarial nature of the American legal system may be perceived as a hostile environment. In the courtroom, opposing attorneys are likely to search for inconsistencies in the testimony or unfamiliarity with the record to discredit the physician witness. 
To avoid being a poor witness, the orthopedist should meticulously prepare to give testimony by conducting a thorough review of the child's medical records and a review of recent medical literature on the subject of child abuse.103 Often, there is a pretestimony discussion with child protective services counsel in family court cases or the district attorney's office in criminal cases. Such meetings should preferably be in person, and the orthopedist's professional training and expertise are examined to determine whether he or she may serve as a material witness, an expert witness, or both. The attorney should be provided the orthopedist's curriculum vitae, and another copy should be made available to the court. If the orthopedist is to serve as a material witness, the factual information of the case as well as the limitations of the physician's knowledge are discussed, as are questions that may be posed during testimony. Orthopedists functioning as expert witnesses should indicate relevant information that should be provided through questioning during testimony. In addition, anticipated testimony from any opposing expert witness and cross-examination questions from the opposing attorney should be discussed. The opposing attorney also may request an informal pretestimony meeting. The orthopedist should request a list of questions that will be asked in this session ahead of time and request that both the prosecution attorney and the opposing attorney be present during the session, which often is recorded. 
The next step may be a deposition in which both attorneys question the witness under oath to “discover” the testimony that the witness will provide in court. The primary purpose for a deposition in the discovery process is to keep attorneys from later being surprised in court by testimony of witnesses.55 Any testimony the physician gives during the deposition will be recorded, and later in court any inconsistencies between testimony and prior depositions are likely to be vigorously attacked by attorneys in cross-examination. Depositions are rarely used in criminal prosecutions103; instead, a subpoena is issued requiring a physician witness to appear at the courtroom at a certain time. Often, there may be hours of delay before the testimony actually begins. Through prior arrangements with the attorneys, the orthopedist may be placed “on call” if he or she works within a reasonable distance of the courtroom and can be available a short time before the actual testimony is needed. The physician has no legal right to such treatment and must be prepared to honor the exact conditions of the subpoena if alternative arrangements cannot be made. If significant delays are encountered in giving testimony and the attorneys are not responsive to physician hardship, then the orthopedist should contact the judge directly to remedy the situation.55 In the courtroom, the orthopedist should be conservatively dressed and appear attentive, competent, poised, and at ease.55,103 
Once called to the stand, the orthopedist is sworn in and identified. Next follows qualification, direct examination, and then cross-examination. In the qualification process, the attorney asks the physician fairly detailed questions about the orthopedist's training and background to establish whether he or she is a credible witness.103 The attorney wishes to impress the judge or jury with the orthopedist's qualifications as a witness, whereas the opposing attorney may challenge the witness with questions to cast doubt on his or her expertise.55 During this phase, the attorneys also may establish the limits of the physician's expertise as an expert medical witness. Next, the attorney will proceed with direct examination. A series of questions are asked that aim at developing a logic and progressive line of thought leading to a conclusion.55 In child abuse cases, in particular, the testimony will lead to the fact that the abuse has occurred and that it has been appropriately diagnosed. In addition, the physician expert witness may be asked to give an opinion of the risk for subsequent abuse if the child returns to the home where the alleged abuse occurred. The physician witness will almost never be asked about the guilt or innocence of the caretaker accused of abuse, but the orthopedist in certain circumstances will come close to answering the “ultimate question”55 by testifying about a child's statement of history if it identifies the abuser. Some states, however, restrict such testimony. In Maryland, a physician may not testify regarding any disclosures made by a child abuse victim unless the disclosure is admissible under a recognized exception to the rule prohibiting hearsay evidence.255 The orthopedist should ask about any possible restrictions on his or her testimony with the attorney in pretrial discussion. In testimony, the orthopedist will want to use the courtroom setting to advocate for the safety and well-being of the child.103 Questions regarding medical findings often will be prefaced in the courtroom by the words “reasonable medical certainty,” a term that is poorly understood by most physicians. Chadwick55 offered a definition of reasonable medical certainty as “certain as a physician should be in order to recommend and carry out treatment for a given medical condition.” He offered an example that the certainty for the diagnosis and treatment of leukemia must be much higher than that for diagnosis and treatment of a viral upper respiratory tract infection. 
During testimony, the orthopedist's words should be carefully chosen and should be understandable by a lay jury. Testimony should be objective, honest, and thorough.103 Attorneys may frame questions in ways that are difficult to understand, and the orthopedist should not hesitate to ask the attorney to clarify a question.55 Answers should be brief, without volunteering extra information. The perception listeners will have of the answers should be carefully considered by the orthopedist. In particular, attorneys may phrase yes or no questions that could place misleading words in the mouth of the orthopedist. In such situations, when neither response is appropriate, the orthopedist should answer in a sentence that provides an accurate answer.103 Language should be straightforward, and visual aids may be used in providing clear testimony. The expert should use testimony as an educational process for the court, in which the common experience and knowledge of the jury is used to build understanding with common sense explanations of medical findings.55 
Cross-examination by the opposing attorney follows direct examination. The opposing attorney's role is to challenge the material presented by the physician witness to protect the defendant.103 This may involve an attempt to bring into question the physician's credibility, the medical record, the physician's training or expertise, or the physician's objectivity or composure and clarity of thought before the jury.103 Attorneys may accomplish this by finding inconsistencies with prior statements, asking leading questions as well as questions that allow only certain desired answers, and minimizing physician qualifications.55 The attorney may frame a question that contains certain elements that the physician agrees with and others that are misleading, and often the question will end with “Isn't that so, doctor?” or “Is that true?” The physician witness should be firm in answering such questions, clearly stating what in the question he or she agrees with and what he or she does not. It is also common to encounter questions from attorneys based on hypotheses that are extremely unlikely, and the physician needs to point out that unlikelihood.55 Part of the strategy of aggressive cross-examination is to provoke the physician into arguments or unprofessional behavior that could discredit the physician or his or her testimony before the court. In particular, juries will allow aggression on the part of an attorney, but they expect physician witnesses to respond professionally, even under extreme duress.73 Inexperienced potential physician witnesses can prepare themselves by either watching trials or participating in mock trials.55 Brent40 assembled an excellent series of vignettes of expert medical witness case studies in court and provided detailed instructions with regard to the responsibilities of such experts. Both redirect examination and recross-examination may follow cross-examination at the discretion of attorneys, but usually these procedures are very short.55 

Disposition Following Custody Hearings

After a hearing or trial, the child historically either remains in the protective custody of the state or returned to home, but the danger of further abuse exists in both situations. In a study of recurrent maltreatment in 10 states based on the NCANDS, Fluke et al.91 found that the recurrence rate was 13% by 6 months after the first episode of reported abuse and return to the home, increasing to 17% by 12 months. In a report of 206 care and protection petitions brought to the Boston juvenile courts,198 31 were dismissed with return of the child to the parents. During a 2-year follow-up of these dismissed cases, 29 had reports of further mistreatment, and 16 were returned to court under another care and protection petition. One risk factor identified by the study was a previous appearance in court; half of dismissed cases with this risk factor returned to court again. Children ordered permanently removed from parental custody by the court may still suffer further abuse by a new caretaker. Another alternative pathway of custody is gaining popularity with the court systems in which the abused child is released to the custody of a relative of the family with consideration given to the wishes of the parents or other prior custodians of the child. Although in theory this approach may help preserve the integrity of the family unit, the child may still be in danger in this sort of arrangement. Handy et al.104 of the Pediatric Forensic Medicine Program of the Kentucky State Medical Examiner's Office noted evidence of recurrent abuse 2 to 9 months after the original injury in 6 patients out of 316 referrals (1.8%) to the program. They emphasized that in two of these cases, the child was in protective custody of a family relative when the original perpetrator was allowed unsupervised access to the child in violation of court order. It is possible that such reinjuries occur because either the close relatives of the child abuser may not believe that the caretaker committed the original abuse or the relatives are under emotional pressure to allow the caretaker to have access to the child in spite of court order. It is hoped that the court systems can strike a balance between the need to preserve the family unit and the need to protect the child from further abuse. 

Prevention of Child Abuse

Prevention of child abuse lies in early intervention. Home visitor programs can contact a mother immediately after the birth of her child and arrange for a visit in which the mother's parenting strengths are assessed. Parents requiring additional support are linked to community agencies and family resources.10,245 Practicing Safety, a project sponsored by the American Academy of Pediatrics (AAP) and funded by the Doris Duke Charitable Foundation, works to decrease child abuse and neglect by expanding anticipatory guidance and increasing screening by pediatric practices to parents of children aged 0 to 3 years. The AAP website (http://www2.aap.org/sections/scan/practicingsafety/phase1.htm) also lists resources for physicians and parents. 
Parenting education offers instruction in specific parenting skills such as discipline methods, basic childcare, infant stimulation, child development, education, and familiarity with local support services. Such support seems to enhance parent and child interactions, and mothers report a diminished need to punish or restrict their children. Antivictimization programs teach children certain concepts believed to facilitate self-protection, such as identification of strangers, types of touching, saying “no” to inappropriate advances, and telling someone about inappropriate behavior. 
Continuing abuse can be prevented by the orthopedist's and trauma team's prompt recognition of child abuse in the emergency department or clinic and appropriate intervention.58 After protecting the welfare of the child, the most important issue in dealing with child abuse is to help both the child and the family through early recognition of the problem and appropriate therapeutic measures by all health personnel. 

Acknowledgments

Special thanks is given to Sreeharsha V. Nandyala for technical assistance with the manuscript and to Drs. Sami Abedin and Reza Zinati for their medical illustrations. 

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Recommended Readings

 

Two references invaluable for preparation for testimony in the courtroom about child abuse:

Chadwick DL. Preparation for court testimony in child abuse cases. Pediatr Clin North Am. 1990; 37:955–970.
Halverson KC, Elliott BA, Rubin MS, et al. Legal considerations in cases of child abuse. Prim Care. 1993; 20:407–415.
 

A handy reference for courtroom testimony involving dating fractures:

O'Connor JF, Cohen J. Dating fractures. In: Kleinman PK, ed. Diagnostic Imaging of Child Abuse. Baltimore, MD: Williams & Wilkins; 1987:168–177.
 

The bible of child abuse radiology:

Kleinman PK. Diagnostic Imaging of Child Abuse. 2nd ed. St. Louis, MO: Mosby; 1998.
 

A current, concise review of the orthopedic detection of child abuse:

Kocher MS, Kasser JR. Orthopaedic aspects of child abuse. J Am Acad Orthop Surg. 2000; 8:10–20.
Newton AW, Vandeven AM. Update on child maltreatment. Curr Opin Pediatr. 2007; 19:223–229.
 

Illustrates the need to keep open mind regarding other diagnoses and the mimics of child abuse:

Laposata ME, Laposata M. Children with signs of abuse. When is it not child abuse?. Am J Clin Path. 2005; 123(suppl 1):S1–S6.
Policy Statement from the AAP Section on Radiology.
Section on Radiology, American Academy of Pediatrics. Diagnostic imaging of child abuse. Pediatrics. 2009; 123(5):1430–1435.
 

Recent summary of role for orthopedic surgeon in child maltreatment:

Sink EL, Hyman JE, Matheny T, et al. Child abuse: The role of the orthopaedic surgeon in nonaccidental trauma. Clin Orthop Relat Res. 2011; 469:790–797.

Other Resources

AAP Section on Child Abuse and Neglect. Available at: www.aap.org/sections/scan.
Child Abuse: Medical Diagnosis and Management. Lecture series of topics in child abuse. Available at: www.aap.org.
Visual Diagnosis of Child Abuse. Available at: www.aap.org. (CD-ROM).