1. “FRACTURES: WHEN TO CONSIDER ABUSE”
ARNE GRAFF MD
MAYO CLINIC-ROCHESTER

2. OBJECTIVES: RECOGNIZE RISK FACTORS ASSOCIATED WITH ABUSE
DEVELOP EVALUATION PROCESS
HOW TO DEVELOP AN IMPRESSION

3. DISCLOSURE:
NONE
DO PARTICIPATE IN COURT CASES FOR BOTH THE DEFENSE AND PROSECUTORS

4. CASE 6 MONTH OLD MALE INFANT PRESENTS WITH MULTIPLE BRUISES NO HISTORY
SKELETAL SURVEY SHOWS DIAPHYSEAL TRANSVERSE FEMUR FRACTURE; NO OTHER INJURIES

5. PA IN CHILDREN
#1 BRUISES
#2 FRACTURES

6. TYPICAL CASE: THERE ISN’T ONE
EACH CASE MUST BE EVALUATED ON THE COMPLETE HISTORY AND WORKUP

7. OUR ROLE: TO PROVE IT’S NOT ABUSE CONSIDER: DIFFERENTIAL DIAGNOSIS:
INJURY = HISTORY = ABILITY = MECHANICS
DIFFERENTIAL DIAGNOSIS:
MEDICAL
ACCIDENTAL: WITNESSED OR UNWITNESSED
NONACCIDENTAL

8. FAILURE TO RECOGNIZE: MORE SERIOUS HARM TO CHILD!

9. THINGS TO CONSIDER: CONSIDER ALL FORMS OF ABUSE COEXISTING
CONSIDER WHOLE PICTURE:
CONSISTENT HISTORY?
TIMELY CARE SOUGHT?
SIGNS AND SYMPTOMS CONSISTENT?

10. STARTING POINT: HISTORY AGE OF CHILD DEVELOPMENT OF CHILD
TYPE OF FRACTURE
LOCATION OF FRACTURE
“AGE” OF FRACTURE
MECHANICS OF INJURY

11. WHO DID IT ?
IN FACT IT IS NOT YOUR JOB OR MINE TO DETERMINE WHO DID IT!
OUR JOB IS TO BE MEDICAL EXPERTS AND EXPLAIN POTENTIAL CAUSE.

13. KEY HISTORY: FMH: FRACTURES, HEARING, DENTAL, GENETICS MEDICATIONS
SOCIAL HISTORY: DV, non-BIOLOGICAL CAREGIVER
PMH: MEDICAL CONDITIONS (renal, etc), PREMIE
NUTRITIONAL: diet, VLGW
SOCIAL SERVICE Hx: abuse, IPV, neglect, other

14. TYPICAL HISTORY: NONE VAGUE MINOR INJURY; INCONSISTENT WITH INJURY
HOWEVER, EVEN MINOR FALL CAN FX!

15. ABUSIVE FRACTURES: 20-30% OF PA VICTIMS MOST OFTEN IN INFANT/TODDLER
80% OF ABUSIVE FX <18 MOS AGE
25% OF FX <1YR OLD ARE ABUSIVE

16. 85% OF NON-ABUSE FRACTURES ARE OVER THE AGE OF 5
HOWEVER, OVERALL ABUSIVE FRACTURS ARE A SMALL PERCENT OF TOTAL PEDS FRACTURES!
85% OF NON-ABUSE FRACTURES ARE OVER THE AGE OF 5

17. CONCERNING FRACTURES:
MULTIPLE FRACTURES
MULTIPLE STAGES OF HEALING
PRESENCE OF SUBPERIOLSTEAL NEW BONE FORMATION (<1 M OR >6 M)

18. KEY POINTS: PRESENCE OF A FRACTURE DOES NOT PROVE ABUSE
NO FRACTURE IS PATHOPNEUMONIC OF ABUSE

20. RED FLAGS: DEVELOPMENT OF CHILD DELAY IN SEEKING CARE
NON-MOBILE CHILD (INFANT)
ANY INFANT FRACTURE WITHOUT HISTORY

21. LACK OF EXTERNAL SIGNS DOES NOT RULE OUT INJURY!

22. HISTORY: INJURY HISTORY PAST MEDICAL HISTORY DEVELOPMENT HISTORY
FAMILY MEDICAL HISTORY
MEDICATIONS
SOCIAL HISTORY

23. KEY CONSIDERATIONS: INJURY = HISTORY
CONSISTENT HISTORY (ER, EMS, YOURS)
DEVELOPMENTAL HISTORY FIT
CHILD’S RESPONSE TO INJURY FIT
INJURY TO CARE TIME
OTHER INJURIES
SOCIAL RISKS

24. ACCIDENTS OCCUR; CAREGIVERS ARE EMBARRESSED!

25. HISTORY CHALLENGES: PROVIDER RELIES ON CAREGIVER HISTORY
OFTEN “NO” HISTORY
PATIENT OFTEN UNABLE TO GIVE HISTORY
LIMITED STUDIES FOR SORTING OUT

26. SYMPTOMS: LIMITED MOVEMENT OF EXTREMITY CRYING OR PAIN WITH MOVEMENT
MAY NOT SEE RESPIRATORY CHANGE
OR……..CRYING AND NOT CONSOLABLE

27. SIGNS: NO BRUISING (8-9%) NO SWELLING NO DEFORMITY
LIMITED TENDERNESS, IF ANY

28. HEAD TO TOES EXAM: INJURIES NEUROLOGICAL EXAM DEVELOPMENTAL EXAM
OTHER FINDINGS (CONNECTIVE TISSUE, ETC)

29. RADIOLOGY EVAL

30. SKELETAL SURVEY AGE INDICATIONS FOR ABUSE: <2: FULL SKELETAL SURVEY
2-5: CASE BY CASE (AGE 2-3)
>5: INDIVIDUAL FILMS OF INJURIES

31. SKELETAL SURVEY: NOT A “BABYGRAM” INCLUDES:
AP VIEWS OF ARMS, FORARMS, HANDS,
FEMURS, LOWER LEGS*, FEET
PA OF CHEST WITH OBLIQUES*
LATERAL OF COMPLETE SPINE
AP AND LATERAL OF SKULL
AP OF PELVIS
LIMITED RADIATION EXPOSURE

32. OBLIQUE VIEW

33. SKELETAL SURVEYS: FIRST SKELETAL SURVEY NEGATIVE; VALUE?
REPEAT SS IN TWO WEEKS
WHAT TO REPEAT; WHAT TO OMIT?

34. SKELETAL SURVEY

35. RADIOLOGY:

36. BONE SCANS: SENSITIVE TEST: NEW RIB FRACTURES (7-10 DAY)
SUBTLE DIAPHYSEAL FRACTURES
EARLY PERIOSTEAL ELEVATIONS
MOST FRACTURES BY 48 HOURS
LESS SENSITIVE:
SKULL FRACTURES
DATING FRACTURES

38. NBPF NEW PERIOSTEAL BONE FORMATION NOT PHYSIOLOGIC: > 2mm
EXTENDS TO METAPHYSIS
NOT LAMINAR
1MONTH < PATIENT AGE > 4 MONTHS

40. GROWTH ARREST LINES NOT SPECIFIC FOR MALTREATMENT SLOW GROWTH TIMES
RELATED TO PHYSIOLOGIC STRESS AS WITH ILLNESS OR STARVATION
BREAK DOWN WITH TIME

43. “GROUND UP STRENGTH”

44. FRACTURE MECHANICS: TRANSVERSE: BENDING LOAD PERPENDICULAR
SPIRAL: TORSION OR TWIST TO LONG AXIS
OBLIQUE: TORSION AND BEND COMBO
BUCKLE: COMPRESSION ALONG LONG AXIS

45. MORE FX MECHANICS:
SHORT FALL ONTO KNEE: torus or impacted transverse distal femur fx
STAIRWAY FALL: twisted lower leg resulting in spiral femur fracture

46. OBLIQUE DISTAL FEMUR FX
No Caption Found
FEMUR FX WITH EXERSAUSER
OBLIQUE DISTAL FEMUR FX
Grant, P. et al. Pediatrics 2001;108:
Copyright ©2001 American Academy of Pediatrics

47. “SERIES OF FALLS”

49. AGE/DEVELOPMENT:
TYPES AND CAUSES VARY FOR DIFFERENT STAGES OF AGE/DEVELOPMENT
FEMUR
TODDLER, SPORTS
? PULL TO STAND
UPPER EXTREMITY
SUPRACONDYLAR, DISTAL FORARM, SWOOSH

50. MECHANICS AND AGE: HUMERAL DIAPHYSEAL FRACTURE SUPRACONDYLAR FRACTURE
<18 MOS; HIGH RISK FOR ABUSE
SUPRACONDYLAR FRACTURE
ABULATORY CHILD; LOW RISK

51. INITIAL DIAGNOSIS; ONE MONTH LATER AND THE BOTTOM ONE IS TWO MONTHS FROM THE FIRST FILM
Kids heal fast!!

52. FRACTURES “SPECIFICITY”
FEMUR: TRANSVERS AND SPIRAL; BOTH
RIBS: >1 FX SUGGESTIVE OF ABUSE
UNILATERAL OR BILATERAL
WITHOUT HX; HIGH SPECIFICITY
SKULL: <3 MOST COMMON; BOTH
PARIETAL
LINEAR
COMPLEX FX ???

53. MUTI-AGED
FRACTURES
MULTIPLE AGED FRATURES

54. rib

55. ACCIDENTAL AND ABUSE FEMUR (toddler fracture)
TIBIA/FIBULA (toddler fracture)
HUMERUS (under 12mos 43% abuse)
RADIUS/ULNA (>5)
SKULL: most common fracture < 2yr
CLAVICLE (most common peds fracture)

56. Orange arrow : toddler fracture
Blue arrow: spiral fracture

57. CML POINTS: CMLS’S: HIGHLY PREDICTIVE IN CHILD <1Y/O
CML: MOST COMMON FRACTURE IN FATAL CASES
CORNER OR BUCKET-HANDLE NAME
PLANAR FX THROUGH PRIMARY SPONGEOSIUM
MECHANICS: TWIST, PULL, SHAKE

58. CMLS

60. OTHER FRACTURES: CLAVICLE: COMMON PEDS INJURY BIRTH TRAUMA (10-14DAY)
USUALLY MIDSHAFT
AC FX—VIOLENT TRACTION
VERTEBRAL: RARE; MRI STUDY
HYPERFLEXION OF TORSO
AND AXIAL SPINE LOADING

61. VERTEBRAL INJURIES: HYPEREXTENSION HYPERFLEXION COMPRESSION
Vertebral body fr

62. HIGH SPECIFICITY MODERATE SPECIFICITY LOW SPECIFICITY
Table 3 Specificity of fracture locations [77].
Specificity Fracture
High Classic metaphyseal lesions
Rib fractures (especially posteromedial)
Scapular fractures
Spinous process fractures
Sternal fractures
Moderate Multiple fractures (especially bilateral)
Fractures of different ages
Epiphyseal separations
Vertebral body fractures and subluxations
Digital fractures
Complex skull fractures
Low Subperiosteal new bone formation
Clavicular fractures
Long-bone shaft fractures
Linear skull fractures
HIGH SPECIFICITY
MODERATE SPECIFICITY
LOW SPECIFICITY

63. HARD TO
DATE!

64. HEALING VARIES:
BY SITE
TYPE OF INJURY
CARE/REINJURY
PARIETAL SKULL FX

65. HEALING FACTORS: IMMOBILIZATION REPEATED TRAUMA DISEASE AGE
SEVERITY OF INJRUY
DEGREE OF DISPLACEMENT

66. HEALING FRACTURES IMPORTANT TO NOTE NORMAL HEALING FOR FRACTURES
NOTE LACK OF NEW FRACTURES WHILE IN FOSTER/KINSHIP CARE

67. NORMAL VARIENTS

68. OTHER RADIOLOGY AIDS

69. 3-D CT

71. Rotator cuff injury
bite
old rib fracture
STIR STUDIES

73. FRACTURE LABS

74. INITIAL LABS: Ca
Phosphorus
Vit D
PTH
ALK PHOS

75. PA’S OTHER LABS:
AMYLASE
LIPASE UA
SGOT, SGPT

76. MEDICAL FX CAUSES: OI OTEOPENIA OF PREMATURIT
OSTEOPENIA BY 6-12 WEEKS OLD
RESOLVES BY 1 YR (IF OTHERWISE DOING WELL)
“TEMPORARY BRITTLE BONE DISEASE”
NOT A CLINICAL ENTITY

77. MEDICAL FX CAUSES: COPPER DEF VIT D DEFICIENCY EDS
PRETERM INFANT
PATHOLOGIC FRACTURES
OTHER: sideroblastic anemia, neutropenia
CHECK: ceruloplasmin, copper
VIT D DEFICIENCY
EDS
OTHER: menke’s, renal, paralysis, etc

78. GENETICS CONSULT? ENDOCRINE (BONE) CONSULT?

80. RICKETS ON LEFT; MENKES ON RIGHT

81. CASE #1 9 MOS INFANT URI RIB FRACTURE NOTED
OTHERWISE NEG SK S AND REPEAT NEG
? ACCIDENTAL; ISOLATED FRACTURE

82. CASE #2 3 YR OLD JUMPING OFF BED DAD REPORTS SHE LANDS AND CRIES OUT
WON’T BEAR WEIGHT
PAST HISTORY NEG
SINGLE DAD; NO CPS HISTORY

83. CASE #2
NEG SKEL SURVEY
PATIENT’S HISTORY

84. YOUR HOSPITAL:
PROTOCOL ? FOR ABUSE/FX
ARTICLES/WORK WITH RADS

85. SUMMARY POINTS: ACCIDENTS CAN FX ANY BONE CONSIDER:
INJURY = HISTORY = ABILITY = MECHANICS
CONSIDER ALL CAUSES FOR FRACTURE (S)