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

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

3. Soft tissue injuries:
Bites.
Burns.
Bruising.

4. Bites:

5. Bruising:

6. 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

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

8. 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
Study group – 35 children.

9. 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

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

11. 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
months
68,288
10.4/1000
Worlock et al, BMJ, 1986

12. 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

13. 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

14. 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

15. Delay in presentation:

16. Patterns of # (aged < 18 months):

17. Patterns of # (aged 19 – 60 months):

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

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

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

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

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

23. 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 %.
Head/face bruise or laceration %.
Linear skull # %.
Limb # (in pt with OI) %.
Nimityongskul & Anderson, 1987

24. 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.

25. 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.

26. 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

27. 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.

28. 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.

29. 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.

30. 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.