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Orthopaedic Aspects Orthopaedic Aspects of Child Abuseof Child Abuse
Assistant Professor and consultant Assistant Professor and consultant Orthopaedic surgeon.Orthopaedic surgeon.
KKUH, KSUKKUH, KSU
Child AbuseChild Abuse
A major cause of disability and death A major cause of disability and death among children.among children.
Fractures are the second most Fractures are the second most common presentation of physical common presentation of physical abuse after skin lesions.abuse after skin lesions.
One third of physically abused One third of physically abused children will require orthopaedic children will require orthopaedic treatment.treatment.
““at a minimum, any act or failure to at a minimum, any act or failure to act resulting in imminent risk of act resulting in imminent risk of serious harm, death, serious serious harm, death, serious physical or emotional harm, sexual physical or emotional harm, sexual abuse, or exploitation of a child by a abuse, or exploitation of a child by a parent or caretaker who is parent or caretaker who is responsible for the child’s welfare.”responsible for the child’s welfare.”
Skin:Skin: Bruises (buttocks, perineum and genitalia, trunk, Bruises (buttocks, perineum and genitalia, trunk,
backbackof head and legs).of head and legs).
Multiple bruises in various stages of healingMultiple bruises in various stages of healing Burns (pattern may reflect mechanism of burn).Burns (pattern may reflect mechanism of burn).
Head and CNS:Head and CNS: Skull fracture (multiple, bilateral, skull base, Skull fracture (multiple, bilateral, skull base,
crossing nervous system suture lines, depressed crossing nervous system suture lines, depressed fractures)fractures)
Chest, abdomen, and pelvis:Chest, abdomen, and pelvis: Rib fractures (posterior, multiple), Rib fractures (posterior, multiple), Sternal fractures and pelvis.Sternal fractures and pelvis. Pneumothorax, hemothoraxPneumothorax, hemothorax Rupture of organ (liver, spleen, or Rupture of organ (liver, spleen, or
pancreas laceration;bowel or bladder pancreas laceration;bowel or bladder rupture)rupture)
Repeat skeletal Repeat skeletal survey at 1-2 weeks survey at 1-2 weeks can be helpfulcan be helpful
2 yo Girl with Proximal 2 yo Girl with Proximal and Distal Humerus Fx, and Distal Humerus Fx,
L2-L3 Fx-DislocationL2-L3 Fx-Dislocation
Bone ScanBone Scan Usually reserved for highly Usually reserved for highly
suspicious cases with negative suspicious cases with negative skeletal surveyskeletal survey
Good at picking up rib fx’s and Good at picking up rib fx’s and vertebral fx’svertebral fx’s
Repeat bone scan at 2 weeks can Repeat bone scan at 2 weeks can identify occult injuriesidentify occult injuries
Multiple Vs single #Multiple Vs single # Multiple fractures in various stages of healing are Multiple fractures in various stages of healing are
found in more than 70% of abused children less than 1 found in more than 70% of abused children less than 1 year of age and more than 50% of all abused children.year of age and more than 50% of all abused children. Krishnan J, Krishnan J, Aust N Z J Surg Aust N Z J Surg 1990 1990
50% of the children had only a single fracture, 33% 50% of the children had only a single fracture, 33%
had two or three fractures, and 17% had more than had two or three fractures, and 17% had more than three fractures.three fractures.
King et al, King et al, J Pediatr Orthop J Pediatr Orthop 19881988 Most common orthopaedic presentation of children Most common orthopaedic presentation of children
with NAT - 65% of children with fx’swith NAT - 65% of children with fx’s Only 13% of children with fractures presented with Only 13% of children with fractures presented with
multiple fractures in different stages of healingmultiple fractures in different stages of healing Loder, JPO 1991Loder, JPO 1991
Patterns of fractures Patterns of fractures
Spiral Vs transverse Spiral Vs transverse 48% to 71% of long-bone fractures in 48% to 71% of long-bone fractures in
several large series are transverse #.several large series are transverse #. no difference in diaphyseal fracture pattern no difference in diaphyseal fracture pattern
between fractures due to abuse and those between fractures due to abuse and those resulting from accidental injury.resulting from accidental injury. Beals ,Beals ,Pediatr Orthop Pediatr Orthop 19831983
no difference in diaphyseal fracture no difference in diaphyseal fracture pattern between fractures due to abuse pattern between fractures due to abuse and those resulting from accidental and those resulting from accidental injury.injury.
Physeal fractures Physeal fractures
Specific bone Specific bone Clavicle:Clavicle:
Most commonly fractured bones in accidental childhood injury.Most commonly fractured bones in accidental childhood injury. Unusual in child abuse, detected in only 2% to 7% of abused Unusual in child abuse, detected in only 2% to 7% of abused
Uncommon in the abused child. Uncommon in the abused child. Transphyseal fractures of the distal humerus in children less Transphyseal fractures of the distal humerus in children less
than 1 year old.than 1 year old. Spinal :(0% to 3%)Spinal :(0% to 3%)
Asymptomatic compression fractures detected on skeletal Asymptomatic compression fractures detected on skeletal survey.survey.
Fracture or avulsion of the spinous processes is fairly specific Fracture or avulsion of the spinous processes is fairly specific to abuse.to abuse.
Hyperflexion and hyperextension associated with violent Hyperflexion and hyperextension associated with violent shaking.shaking.
Specific boneSpecific bone
FemureFemure Most femur fx’s in children who are < 1 Most femur fx’s in children who are < 1
yo of age are from NAT (60-70%) yo of age are from NAT (60-70%) Most femur fx’sMost femur fx’s in children > 1 yo in children > 1 yo
accidentalaccidental
Humerus Fx’sHumerus Fx’s
Diaphyseal fx’s Diaphyseal fx’s in children < 3 in children < 3 yo are very yo are very suggestive of suggestive of NAT!!!!!!!NAT!!!!!!!
Humerus Fx’sHumerus Fx’s
Most common fx in some seriesMost common fx in some series Supracondylar fx’s common in Supracondylar fx’s common in
accidental traumaaccidental trauma Transphyseal fx’s - high Transphyseal fx’s - high
association with NATassociation with NAT
Transphyseal Transphyseal Humerus Humerus
Common in Common in NATNAT
Metaphyseal Vs Metaphyseal Vs diaphysealdiaphyseal
Metaphyseal injuries are less Metaphyseal injuries are less common than diaphyseal fractures.common than diaphyseal fractures.
Metaphyseal lesions have high Metaphyseal lesions have high specificity and are considered to be specificity and are considered to be a “classic” radiographic finding in a “classic” radiographic finding in physical abusephysical abuse
Metaphyseal or Bucket Metaphyseal or Bucket Handle Fx’sHandle Fx’s
Mechanism – traction and twistingMechanism – traction and twisting Planar injuries through the primary Planar injuries through the primary
spongiosumspongiosum May be picked up at autopsy when May be picked up at autopsy when
not seen on x-raynot seen on x-ray
Corner FracturesCorner Fractures
Traction/rotation Traction/rotation mechanism of mechanism of injuryinjury
Planar fracture Planar fracture through primary through primary spongiosa, creates spongiosa, creates disklike fragment disklike fragment of bone/cartilage, of bone/cartilage, thicker at thicker at peripheryperiphery
Metaphyseal or Bucket Metaphyseal or Bucket Handle Fx’sHandle Fx’s
Professional, tactful, nonjudgmental Professional, tactful, nonjudgmental approach in initial encounter and approach in initial encounter and workup workup
Explain workup to parents as standard Explain workup to parents as standard approach to specific ages/injury patternsapproach to specific ages/injury patterns
Early involvement of child protection Early involvement of child protection team if availableteam if available
Early contact/involvement of child’s Early contact/involvement of child’s primary care physicianprimary care physician