Non-accidental injury and the Orthopaedic Surgeon. Peter Worlock Newcastle General Hospital

Role of doctors: Be aware of problem. Recognise unusual injury patterns. Initiate investigation.

Soft tissue injuries: Bites. Burns. Bruising.

Bites:

Bruising:

Soft tissue injuries – normal children: Head/face injuries rare <18 months. Lumbar injuries unusual before age of 5 years. Bruising of hands/feet and lower legs is most common injury. Roberton et al, 1982

Soft tissue injuries – NAI: Head/face injuries present in 60%. Lumbar injuries common under age of 5 years. Roberton et al, 1982

Fracture pattern: Accidental Injury (AI) – all children aged <13 years living in Nottingham Jan-June 1981 with a #. Study group – 826 consecutive children. Non-accidental injury (NAI) – all children aged <13 years in Nottingham with # from child abuse 1976-1982. Study group – 35 children.

Distribution by age (p<001): NAI (n = 35) AI (n = 826) < 18 months 28 (80%) 19 (2.3%) 19 – 60 months 7 (20%) 97 (11.8%) 61 – 155 months - 710 (85.9%) Worlock et al, BMJ, 1986

Age - and sex-specific incidence rates – # caused by AI:

AI group # incidence during six month study period (p<0.001): Pop. at risk Incidence < 18 months 10,989 1.7/1000 19 – 60 months 23,564 4.8/1000 61 -155 months 68,288 10.4/1000 Worlock et al, BMJ, 1986

Annual # incidence (NAI : AI): < 18 months 4/10,000 34/10,000 19 – 60 months 0.4/10,000 96/10,000 Worlock et al, BMJ, 1986

Number of fractures per child aged < 60 months (p<0.001): NAI (n = 35) AI (n = 116) 1 # only 9 97 2 # only 7 19 > 2 # - Worlock et al, BMJ, 1986

Association with other injuries (p<0.001): NAI (n = 35) AI (n = 116) None 6 99 Burn 1 - Minor HI 3 16 Trunk bruise 4 Limb bruise Head bruise 18 Worlock et al, BMJ, 1986

Delay in presentation:

Patterns of # (aged < 18 months):

Patterns of # (aged 19 – 60 months):

Metaphyseal ‘chip’ #: Said to be “classic” pattern of # in NAI. Less common than often thought.

Rib #: Present in 54% of children in NAI group. None seen in AI group. All diagnosed on skeletal survey, after abuse suspected.

Spiral # of humeral shaft: Seen in 9 out of 35 children in NAI group. None seen in AI group (p<0.001)

Skull # after NAI: Multiple or complex #. Involvement of more than one bone. Non-parietal #. Depressed #. ‘Growing’ #.

Femoral # in children aged < 4 years: Aetiology: Normal trauma/normal children 49%. Child abuse 30%. Pathological 12.5%. Major trauma 8.5%. Beals and Tuft, 1983

Risk of injury on falling out of bed: 76 children fallen from bed, cot or chair. Height of falls from 1 – 3 ft. Injuries: Minor bruise/no injury 63.5%. Head/face bruise or laceration 30.0%. Linear skull # 1.3%. Limb # (in pt with OI) 1.3%. Nimityongskul & Anderson, 1987

NAI and osteogenesis imperfecta: Type I: autosomal dominant with blue sclera. Most common type. Type II: autosomal recessive with blue sclera. Lethal in foetal or perinatal period. Type III: autosomal recessive with normal sclera. Moderate/severe bone fragility with rapidly progressive deformity.

NAI and osteogenesis imperfecta: Type IV: autosomal dominant, but occasional spontaneous mutation. Normal sclera. Mild/moderate bone fragility with variable deformity. Rare! Incidence: 1 in 120,000 live births.

NAI and osteogenesis imperfecta: Occurrence in absence of blue sclera, no family history and lack of progressive deformity is about 1 in 3,000,000 live births. A city of 500,000 people with 6000 live births per year would produce one case of Type IV OI by spontaneous mutation every 100 – 300 years. Taitz, BMJ, 1987

Other conditions causing spontaneous # in infancy : Prematurity. Usually <1500g at birth, with evidence of rickets and/or osteoporosis on XR. Raised Alk. Phosphatase. Copper deficiency. Can occur in pre-term babies given Cu-deficient feed, after TPN lacking Cu or in severe malabsorption with Cu-deficient diet. Children with # all have severe haematological abnormalities and osteoporosis on XR.

NAI and the Orthopaedic Surgeon: # uncommon in normal children < 18 months, but # due to NAI most common in this age group. 1 child in 8 aged < 18 months with a # may be victim of abuse. Rib # on skeletal survey, in absence of major chest trauma, is virtually diagnostic of NAI.

NAI and the Orthopaedic Surgeon: Metaphyseal ‘chip’ # relatively uncommon. Diaphyseal injuries in NAI are due to gripping/twisting – spiral # or periosteal new bone formation. You need to be able to recognise unusual injury patterns.

NAI and the Orthopaedic Surgeon: Be prepared to initiate investigation. Know your own hospital’s procedure for investigating suspected NAI. Do not accuse parents – leave interviewing family to the experts. Children’s Act 1992 – safety and well-being of the child is paramount.