Orthopaedic Aspects Orthopaedic Aspects of Child Abuseof Child Abuse

NATNATAbdulaziz Alomar, MD, MSc FRCSCAbdulaziz Alomar, MD, MSc FRCSC

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.”

Definition Definition

Type of Maltreatment Type of Maltreatment

1.1. Neglected (52%)Neglected (52%)

2.2. Physical abuse (25%)Physical abuse (25%)

3.3. Sexual abuse (13%)Sexual abuse (13%)

4.4. Emotional maltreatment (5%)Emotional maltreatment (5%)

5. Medical neglect (3%)5. Medical neglect (3%)

Risk factors Risk factors First-born children.First-born children. Unplanned children.Unplanned children. Premature infants. Premature infants. Stepchildren. Stepchildren. Handicapped children.Handicapped children. Single-parent homes. Single-parent homes. Drug abusing parents.Drug abusing parents. Parents who were themselves abused.Parents who were themselves abused. Unemployed parents.Unemployed parents. Families of lower socioeconomic status.Families of lower socioeconomic status.

The majority of maltreated The majority of maltreated childrenchildrenare abused by birth are abused by birth parents.parents.

Who is at Risk?Who is at Risk?

Most children with NAT fractures - Most children with NAT fractures -

age of < 3 yearsage of < 3 years

Who’s at Risk?Who’s at Risk?

Most femur fx’s Most femur fx’s in children who in children who are < 1 yo of age are < 1 yo of age are from NAT are from NAT (60-70%) (60-70%)

Most femur fx’sMost femur fx’sin children > in children >

1yo accidental1yo accidental

Clinical FeaturesClinical Features

History:History: Delay in presenting.Delay in presenting. History vague, lacking in detail, History vague, lacking in detail,

contradictorycontradictory Mechanism of injury insufficient to Mechanism of injury insufficient to

explain injuriesexplain injuries History of a fallHistory of a fall

History :History : Less than 3 years oldLess than 3 years old Poor household environment, drug or Poor household environment, drug or

physical abusephysical abuse Overly aggressive or passiveOverly aggressive or passive Behavioral problemsBehavioral problems Handicapped childHandicapped child StepchildStepchild Premature childPremature child Subnormal growthSubnormal growth

Clinical FeaturesClinical Features

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)

Subdural hematoma, subarachnoid hemorrhageSubdural hematoma, subarachnoid hemorrhage Retinal hemorrhage, retinal detachmentRetinal hemorrhage, retinal detachment Cognitive disabilitiesCognitive disabilities

Non Orthopaedic FeaturesNon Orthopaedic Features

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)

Intramural bowel hematomaIntramural bowel hematoma Kidney contusion, retroperitoneal Kidney contusion, retroperitoneal

hemorrhagehemorrhage Sexual abuseSexual abuse

Non Orthopaedic FeaturesNon Orthopaedic Features

Orthopaedic FeaturesOrthopaedic Features

Multiple fractures system Multiple fractures system Fractures in various stages of Fractures in various stages of

healinghealing Metaphyseal corner fractureMetaphyseal corner fracture Long-bone fracture in child <2 yrLong-bone fracture in child <2 yr Vertebral compression fractures, Vertebral compression fractures,

spinous process avulsion.spinous process avulsion. Scapular fractureScapular fracture Epiphyseal separationEpiphyseal separation

Fractures Commonly Fractures Commonly seen in NAT - High seen in NAT - High

SpecificitySpecificity Femur fracture in child Femur fracture in child < 1 year old< 1 year old

Humeral shaft fracture Humeral shaft fracture in < 3 year oldin < 3 year old

Sternal fracturesSternal fractures Metaphyseal corner Metaphyseal corner

(bucket-handle) (bucket-handle) fracturesfractures

Posterior rib fxsPosterior rib fxs Digit fractures in Digit fractures in

nonambulatory nonambulatory childrenchildren

50% to 69% of all fractures occurred 50% to 69% of all fractures occurred in children less than 1year of age.in children less than 1year of age.

78% to 85% occurred in children 78% to 85% occurred in children less than 3 years of age.less than 3 years of age.

Timetable for Estimating the Timetable for Estimating the Age of Fractures in ChildrenAge of Fractures in Children

Radiographic AppearanceRadiographic Appearance EarlyEarly Peak Peak Late Late

Resolution of soft-tissue swelling, daysResolution of soft-tissue swelling, days 2-52-5 4-104-10 10-2110-21

New periosteal bone, daysNew periosteal bone, days 4-104-10 10-1410-14 14-2114-21

Loss of definition of fracture line, daysLoss of definition of fracture line, days 10-1410-14 14-2114-21 21-4221-42

Presence of soft callus, daysPresence of soft callus, days 10-1410-14 14-2114-21 21-2821-28

Presence of hard callus, daysPresence of hard callus, days 14-2114-21 21-4221-42 42-9042-90

Remodeling of fracture, monthsRemodeling of fracture, months 33 1212 2424

Radiographic W/URadiographic W/U Skeletal survey for children with Skeletal survey for children with

suspicion of NATsuspicion of NAT ““Babygram” not sufficient as does Babygram” not sufficient as does

not provide necessary detail to not provide necessary detail to identify fracturesidentify fractures

Radiographic Work-UpRadiographic Work-Up

Skeletal surveySkeletal survey AP/LAT skull, AP/LAT skull, AP/LAT axial AP/LAT axial

skeleton and trunk, skeleton and trunk, AP bilateral arms, AP bilateral arms,

forearms, hands, forearms, hands, thighs, legs, feetthighs, legs, feet

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

children.children. physeal fractures:physeal fractures:

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

Pathognomonic ofPathognomonic of NAT NAT

MetaphysealMetaphyseal Bucket Bucket

HandleHandleFxFx

Differential DiagnosisDifferential Diagnosis

Osteogenesis imperfectaOsteogenesis imperfecta Accidental injuryAccidental injury Birth traumaBirth trauma RicketsRickets Coagulation disordersCoagulation disorders LeukemiaLeukemia Congenital insensitivity to painCongenital insensitivity to pain

Management - NAT Management - NAT SuspectedSuspected

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

Management - Management - DocumentationDocumentation

Many cases result in medical records Many cases result in medical records becoming part of legal recordbecoming part of legal record

Carefully document history, physical Carefully document history, physical exam and radiographic findingsexam and radiographic findings

Document evidence supporting Document evidence supporting physical abusephysical abuse

Document statement regarding level Document statement regarding level of certainty of abuseof certainty of abuse