1. Orthopaedic Aspects of Child Abuse NAT Abdulaziz Alomar, MD, MSc FRCSC Assistant Professor and consultant Orthopaedic surgeon. KKUH, KSU

2. Child Abuse A major cause of disability and death among children. A major cause of disability and death among children. Fractures are the second most common presentation of physical abuse after skin lesions. Fractures are the second most common presentation of physical abuse after skin lesions. One third of physically abused children will require orthopaedic treatment. One third of physically abused children will require orthopaedic treatment.

3. “at a minimum, any act or failure to act resulting in imminent risk of serious harm, death, serious physical or emotional harm, sexual abuse, or exploitation of a child by a parent or caretaker who is responsible for the child’s welfare.” Definition

4. Type of Maltreatment 1. Neglected (52%) 2. Physical abuse (25%) 3. Sexual abuse (13%) 4. Emotional maltreatment (5%) 5. Medical neglect (3%)

5. 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.

6. The majority of maltreated children are abused by birth parents.

7. Who is at Risk? Most children with NAT fractures - Most children with NAT fractures - age of < 3 years

8. Who’s at Risk? Most femur fx’s in children who are < 1 yo of age are from NAT (60-70%) Most femur fx’s in children who are < 1 yo of age are from NAT (60-70%) Most femur fx’sin children > 1yo accidental Most femur fx’sin children > 1yo accidental

9. Clinical Features History: History: Delay in presenting. Delay in presenting. History vague, lacking in detail, contradictory History vague, lacking in detail, contradictory Mechanism of injury insufficient to explain injuries Mechanism of injury insufficient to explain injuries History of a fall History of a fall

10. History : History : Less than 3 years old Less than 3 years old Poor household environment, drug or physical abuse Poor household environment, drug or physical abuse Overly aggressive or passive Overly aggressive or passive Behavioral problems Behavioral problems Handicapped child Handicapped child Stepchild Stepchild Premature child Premature child Subnormal growth Subnormal growth Clinical Features

11. Skin: Skin: Bruises (buttocks, perineum and genitalia, trunk, back Bruises (buttocks, perineum and genitalia, trunk, back of head and legs). Multiple bruises in various stages of healing Multiple 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, crossing nervous system suture lines, depressed fractures) Skull fracture (multiple, bilateral, skull base, crossing nervous system suture lines, depressed fractures) Subdural hematoma, subarachnoid hemorrhage Subdural hematoma, subarachnoid hemorrhage Retinal hemorrhage, retinal detachment Retinal hemorrhage, retinal detachment Cognitive disabilities Cognitive disabilities Non Orthopaedic Features

12. 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, hemothorax Pneumothorax, hemothorax Rupture of organ (liver, spleen, or pancreas laceration;bowel or bladder rupture) Rupture of organ (liver, spleen, or pancreas laceration;bowel or bladder rupture) Intramural bowel hematoma Intramural bowel hematoma Kidney contusion, retroperitoneal hemorrhage Kidney contusion, retroperitoneal hemorrhage Sexual abuse Sexual abuse Non Orthopaedic Features

14. Orthopaedic Features Multiple fractures system Multiple fractures system Fractures in various stages of healing Fractures in various stages of healing Metaphyseal corner fracture Metaphyseal corner fracture Long-bone fracture in child <2 yr Long-bone fracture in child <2 yr Vertebral compression fractures, spinous process avulsion. Vertebral compression fractures, spinous process avulsion. Scapular fracture Scapular fracture Epiphyseal separation Epiphyseal separation

15. Fractures Commonly seen in NAT - High Specificity Femur fracture in child < 1 year old Femur fracture in child < 1 year old Humeral shaft fracture in < 3 year old Humeral shaft fracture in < 3 year old Sternal fractures Sternal fractures Metaphyseal corner (bucket-handle) fractures Metaphyseal corner (bucket-handle) fractures Posterior rib fxs Posterior rib fxs Digit fractures in nonambulatory children Digit fractures in nonambulatory children

16. 50% to 69% of all fractures occurred in children less than 1year of age. 50% to 69% of all fractures occurred in children less than 1year of age. 78% to 85% occurred in children less than 3 years of age. 78% to 85% occurred in children less than 3 years of age.

17. Timetable for Estimating the Age of Fractures in Children Radiographic Appearance EarlyPeakLate Resolution of soft-tissue swelling, days 2-54-1010-21 New periosteal bone, days 4-1010-1414-21 Loss of definition of fracture line, days 10-1414-2121-42 Presence of soft callus, days 10-1414-2121-28 Presence of hard callus, days 14-2121-4242-90 Remodeling of fracture, months 31224

18. Radiographic W/U Skeletal survey for children with suspicion of NAT Skeletal survey for children with suspicion of NAT “Babygram” not sufficient as does not provide necessary detail to identify fractures “Babygram” not sufficient as does not provide necessary detail to identify fractures

19. Radiographic Work-Up Skeletal survey AP/LAT skull, AP/LAT skull, AP/LAT axial skeleton and trunk, AP/LAT axial skeleton and trunk, AP bilateral arms, forearms, hands, thighs, legs, feet AP bilateral arms, forearms, hands, thighs, legs, feet Repeat skeletal survey at 1-2 weeks can be helpful Repeat skeletal survey at 1-2 weeks can be helpful

20. 2 yo Girl with Proximal and Distal Humerus Fx, L2-L3 Fx- Dislocation

21. Bone Scan Usually reserved for highly suspicious cases with negative skeletal survey Usually reserved for highly suspicious cases with negative skeletal survey Good at picking up rib fx’s and vertebral fx’s Good at picking up rib fx’s and vertebral fx’s Repeat bone scan at 2 weeks can identify occult injuries Repeat bone scan at 2 weeks can identify occult injuries

22. Multiple Vs single # Multiple fractures in various stages of healing are found in more than 70% of abused children less than 1 year of age and more than 50% of all abused children. Multiple fractures in various stages of healing are found in more than 70% of abused children less than 1 year of age and more than 50% of all abused children. Krishnan J, Aust N Z J Surg 1990 Krishnan J, Aust N Z J Surg 1990 50% of the children had only a single fracture, 33% had two or three fractures, and 17% had more than three fractures. 50% of the children had only a single fracture, 33% had two or three fractures, and 17% had more than three fractures. King et al, J Pediatr Orthop 1988 King et al, J Pediatr Orthop 1988 Most common orthopaedic presentation of children with NAT - 65% of children with fx’s Most common orthopaedic presentation of children with NAT - 65% of children with fx’s Only 13% of children with fractures presented with multiple fractures in different stages of healing Only 13% of children with fractures presented with multiple fractures in different stages of healing Loder, JPO 1991 Loder, JPO 1991

23. Patterns of fractures Spiral Vs transverse Spiral Vs transverse 48% to 71% of long-bone fractures in several large series are transverse #. 48% to 71% of long-bone fractures in several large series are transverse #. no difference in diaphyseal fracture pattern between fractures due to abuse and those resulting from accidental injury. no difference in diaphyseal fracture pattern between fractures due to abuse and those resulting from accidental injury. Beals,Pediatr Orthop 1983 Beals,Pediatr Orthop 1983 no difference in diaphyseal fracture pattern between fractures due to abuse and those resulting from accidental injury. no difference in diaphyseal fracture pattern between fractures due to abuse and those resulting from accidental injury.

25. Physeal fractures

26. 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 children. Unusual in child abuse, detected in only 2% to 7% of abused children. physeal fractures: physeal fractures: Uncommon in the abused child. Uncommon in the abused child. Transphyseal fractures of the distal humerus in children less than 1 year old. Transphyseal fractures of the distal humerus in children less than 1 year old. Spinal :(0% to 3%) Spinal :(0% to 3%) Asymptomatic compression fractures detected on skeletal survey. Asymptomatic compression fractures detected on skeletal survey. Fracture or avulsion of the spinous processes is fairly specific to abuse. Fracture or avulsion of the spinous processes is fairly specific to abuse. Hyperflexion and hyperextension associated with violent shaking. Hyperflexion and hyperextension associated with violent shaking.

27. Specific bone Femure Femure Most femur fx’s in children who are < 1 yo of age are from NAT (60-70%) Most femur fx’s in children who are < 1 yo of age are from NAT (60-70%) Most femur fx’sin children > 1 yo accidental Most femur fx’sin children > 1 yo accidental

28. Humerus Fx’s Diaphyseal fx’s in children < 3 yo are very suggestive of NAT!!!!!!! Diaphyseal fx’s in children < 3 yo are very suggestive of NAT!!!!!!!

29. Humerus Fx’s Most common fx in some series Most common fx in some series Supracondylar fx’s common in accidental trauma Supracondylar fx’s common in accidental trauma Transphyseal fx’s - high association with NAT Transphyseal fx’s - high association with NAT

30. Transphyseal Humerus Common in NAT Common in NAT

31. Metaphyseal Vs diaphyseal Metaphyseal injuries are less common than diaphyseal fractures. Metaphyseal injuries are less common than diaphyseal fractures. Metaphyseal lesions have high specificity and are considered to be a “classic” radiographic finding in physical abuse Metaphyseal lesions have high specificity and are considered to be a “classic” radiographic finding in physical abuse

32. Metaphyseal or Bucket Handle Fx’s Mechanism – traction and twisting Mechanism – traction and twisting Planar injuries through the primary spongiosum Planar injuries through the primary spongiosum May be picked up at autopsy when not seen on x-ray May be picked up at autopsy when not seen on x-ray

33. Corner Fractures Traction/rotation mechanism of injury Traction/rotation mechanism of injury Planar fracture through primary spongiosa, creates disklike fragment of bone/cartilage, thicker at periphery Planar fracture through primary spongiosa, creates disklike fragment of bone/cartilage, thicker at periphery

36. Metaphyseal or Bucket Handle Fx’s Pathognomonic of NAT Pathognomonic of NAT

37. Metaphyseal Bucket Handle Fx

38. Differential Diagnosis Osteogenesis imperfecta Osteogenesis imperfecta Accidental injury Accidental injury Birth trauma Birth trauma Rickets Rickets Coagulation disorders Coagulation disorders Leukemia Leukemia Congenital insensitivity to pain Congenital insensitivity to pain

39. Management - NAT Suspected Professional, tactful, nonjudgmental approach in initial encounter and workup Professional, tactful, nonjudgmental approach in initial encounter and workup Explain workup to parents as standard approach to specific ages/injury patterns Explain workup to parents as standard approach to specific ages/injury patterns Early involvement of child protection team if available Early involvement of child protection team if available Early contact/involvement of child’s primary care physician Early contact/involvement of child’s primary care physician

40. Management - Documentation Many cases result in medical records becoming part of legal record Many cases result in medical records becoming part of legal record Carefully document history, physical exam and radiographic findings Carefully document history, physical exam and radiographic findings Document evidence supporting physical abuse Document evidence supporting physical abuse Document statement regarding level of certainty of abuse Document statement regarding level of certainty of abuse