ABC of Child Abuse

FRACTURESC J Hobbs

Metaphysial (corner) fractureoflower end offemur in a childof15 months, who was swungby the legs and hit head againsta wall

Distal metaphysial chipfractures oflower end of tibiaandfibula in abused infant

Dr C J Hobbs, MRCP, iSconsultant communitypaediatrician at St James'sUniversity Hospital, Leeds.

Fractures are among the most serious injuriessustained after physical abuse. They may occur inalmost any bone and may be single or multiple,clinically obvious or occult and detectable only byradiography.

PrevalenceIn one study of physically abused children

more than half of the children (58%) were under 3years old and they sustained most of the fractures(94%). In contrast, accidental fractures occurmore commonly in children of school age.The proportion of children presenting to

hospital with fractures resulting from physicalabuse rises to a maximum during the first year oflife, when it may be as high as a half. A great dealof suspicion is required at this age. Mostaccidental fractures in infants and toddlers resultfrom falls, although fractures are uncommon infalls of under a metre.As early detection improves the proportion of

children with fractures who are identified ashaving been physically abused falls from 50% to10% or less. Most children with serious injuryhave suffered minor injury or shown other signsofabuse that have not been recognised or acted onby professionals in contact with the child.

Detecting fractures due to physical abuseChildren whose fractures are the result of an

accident present crying excessively, with swellingor bruising, and are reluctant to use the affectedpart-for example, to put weight on a leg.Some fractures caused by physical abuse are

detected only by radiology because the fracturemay be old, the physical signs having regressed;the site may be hidden-for example, the ribs,pelvis, or skull -and the parents will not havedrawn attention to the possibility of injury.

Important patternsSix important patterns are seen in fractures

caused by physical abuse. These are (a) a singlefracture with multiple bruises; (b) multiplefractures in different stages of healing, possiblywith no bruises or soft tissue injuries; (c)metaphysial-epiphysial injuries, which areoften multiple; (d) rib fractures; (e) theformation of new periosteal bone; and (/) a skullfracture in association with intracranial injury.As with all forms of physical abuse a careful

history and examination and appraisal of the'

BMJ VOLUME 298 15 APRIL 1989 1015

Distal non-displacedfractureoflower shafts oftibia andfibula in abused child of6months, with evidence ofperiosteal reaction along tibialshafts. Fracture is probably10-14 days old. Other injuriesincluded multiple rib andcomplex skullfractures

family potential for child abuse provides theframework for diagnosis.

Skeletal surveyThe radiographic survey of the child's skeleton

must be complete. Babygrams (the whole baby inone radiograph) are generally unacceptable.

fractures are specific for physical abuse in youngchildren.

Cardiopulmonary resuscitation does not causerib fractures in this age group.

Rib fractures are often multiple.and bilateraland occur posteriorly. They are caused bythoracic compression, which often occurs withshaking and from kicks or blows in olderchildren. Recent fractures are difficult to see butare more obvious later when callus forms asbeaded shafts after about 10-14 days.

Metaphysial and epiphysial fracturesMetaphysial and epiphysial fractures are the

classic injuries of physical abuse. Fragments ofbone become separated from the ends of longbones either as a chip or as a whole plate. Suchinjuries arise from acceleration and decelerationas the infant is shaken by the body, arms or legs.The forces of pulling and twisting applied to theweak metaphysial areas of bone disrupt a finelayer of new trabecular bone close to the junctionwith cartilage. In epiphysial lesions the injuryoccurs in the zone of hypertrophic cartilage withfew radiological signs initially. The usual sites arethe knee, wrist, elbow, and ankle.

Fractures of the shafts of long bonesSpiral, oblique, or transverse fractures arise in

the shafts of long bones from indirect trauma-

Specificity ofradiologicalfindingsNo lesion is absolutely pathognomonic of

physical abuse but some carry higher specificitythan others.High specificity findings are metaphysial or

epiphysial fractures, or both (corner and buckethandle fractures, chip fractures); rib fractures;multiple or wide complex skull fractures, or

both; scapular and sternal fractures, which are

uncommon; multiple fractures; fractures ofdifferent ages; and unpresented fractures.Low specificity findings are single fractures;

linear, narrow parietal skull fractures; fracturesin the shaft of long bones; and clavicularfractures.

Rib fracturesRib fractures are usually occult and detected

only by careful radiology, unless there is historyof direct trauma to the rib cage -for example, aroad traffic accident -or bone disease. Rib

Mid-shaftfracture ofradius and ulna in 14 month old girl with oldbruising to her thigh andfailure to thrive. Fracture in itselfcarrieslittle specificity for physical abuse, but bruising and growth chart(overleaf) greatly increase likelihood ofphysical abuse.Cohabiting boyfriend ofgirl's mother admitted swinging child byarm

BMJ VOLUME 298 15 APRIL 1989

Consider skeletal survey

* When injury or history suggest physicalabuse* In all children less than 18 months old* In older children with severe bruising* For localised pain, limp, or reluctance touse arm or leg* When history of skeletal injury* In children dying in unusual orsuspicious circumstances.

Growth chart of14 month oldgirl with fractured tibia andfibula in case describedoverleaf. Pattern offailure tothrive developedfrom age of4months, when care wastransferred to an aunt, andworsened when natural mothertook over care at about 12months. Catch up in length andweight were seen in fostermother's care. Children mayreact to changes in carer bydeveloping behaviouraldifficulties, often centred onfeeding, which may triggerviolent responsesfrom parents

Posterior healing rib fracturesofleft sixth, seventh, andeighth ribs behind cardiacshadow in abused infant.Presence ofcallus and unclearfracture line suggests fracturesare at least two weeks old

for example, being swung by the arms -or directtrauma -for example, being hit acrossstraightened arms with an iron bar, which causessymmetrical transverse fractures of the lowerthird of both radii.

Spiral fracture of the humerus was found to besignificantly more common in physical abusethan in accidents in one study, but all types offractures can arise either from physical abuse oran accident. Only the history or presence ofotherinjuries will help differentiate between the two.

-Spinal injurySpinal injury in physical abuse usually results

from hyperflexion-extension injury with damageto several consecutive levels. Defects in thelucency of the anterior superior edges of thevertebral bodies, often in the lower thoracic andupper lumbar region, with narrowed disc spacesare characteristic. Multiple spinous processfractures are also described. Spinal cord injurymay follow dislocation or subluxation.

Formation ofnew periosteal boneInjury to an infant's developing long bone

often results in subperiosteal haemorrhage,which raises the periosteum from the shaft whilemaintaining its firm attachment to the epiphysis.This process usually takes 10-14 days to appear,and radiography may yield negative resultsinitially. The finding may also point to anunderlying fracture' that is not easily visualised.

Such injuries probably arise when arms andlegs are grabbed, pulled, or used as a handle forshaking thegichild. Trauma must be distinguishedfrom other causes -namely, infection, Caffey'sdisease, vitamin A intoxication, leukaemia, andcertain drugs -but all of these are far lesscommon than physical abuse.

Dating fracturesThe dating of fractures is of obvious

medicolegal importance. Fractures heal indistinct stages, which can be detectedradiographically, according to a set time scale,shown in the table. The table gives peak times;sometimes the earliest changes are seen a few daysbefore this.

Resolution of soft tissue change 4-10 daysPeriosteal new bone formation(earliest sign) 10-14 daysLoss of fracture line definition 14-21 daysSoft callus 14-21 daysHard callus 21-42 daysRemodelling 1 year

From: Kleinman PK. Diagnostic imaging ofchildabuse. Baltimore: Williams and Wilkins, 1987.

Repetitive injury to fractures that have notbeen medically treated may prolong the healingstages. Infants tend to heal more quickly thanolder children. Refracture through an olduntreated fracture can be recognised by thepresence of well developed callus around afresh fracture with a clearly visible fracture line.

Differential diagnosis of fracturesChild abuse is common. Non-traumatic causes

of fracture or pseudofracture vary fromuncommon to extremely rare. A balancedperspective is required if children's interests areto be preserved. Courts for the protection of

BMJ VOLUME 298 15 APRIL 1989 11017

Distal humerus epiphysialseparation in 5 month oldinfant with 25 separatenon-accidental injuries,includingfivefractures. New boneInitially injury was confused _ bone

with dislocation but on followup four weeks later extensiveformation ofmedial new bone(right) confirmed displacementofepiphysis

Spinal injury in abused 6yearold child. Characteristtc injuryis present

3ArterAnterior superiornotching

Narrow discspaces

children require probability rather than certaintyin evidence.Normal variants-The formation ofnew

periosteal bone in infants and unusual suturelines on a skull radiograph could be normalvariants.

Birth trauma-During breech deliveries theclavicle and humerus are often broken. If,however, callus is absent two weeks after birththe fracture did not occur during delivery.Bone disease-Osteogenesis imperfecta, rickets

of prematurity, disuse osteoporosis, copperdeficiency, Caffey's disease, and osteomyelitiscan cause fractures and need to be excluded.Features in the history and examination,however, help to exclude these uncommonconditions. Expert radiological, paediatric, andbiochemical help may be needed in occasional

cases. The presence of a normal skeletonradiologically is strongly against the diagnosis ofgenetic, metabolic, or bone disease. In Leedsover 10 years fewer than five cases of physicalabuse have been confused with bone disease.

I thank DrM F G Buchanan for his help and the staffof the Department of Medical Illustration, St James'sUniversity Hospital, Leeds, for their help with theillustrations.

Further readingKleinman PK. Diagnostic imaging ofchild abuse. Baltimore:Williams and Wilkins, 1987.

The ABC of Clinical Genetics will continue next week. Thefourth article in this series, which has been edited byProfessor Roy Meadow, will appear on 29 April.

ANY QUESTIONSWhat are the important cardiovascular abnormalities seen in patients withhypercalcaemia secondary to primary hyperparathyroidism, and what pre-cautions are advised before surgery ofthe parathyroid gland in these patients?

The principal cardiac abnormalities of hypercalcaemia are shortening ofthe QT interval in the electrocardiogram, arrhythmias including heartblock and cardiac arrest,' and raised blood pressure. Other possibleeffects include coronary artery spasm, a direct depressant effect on themyocardium, and calcium deposition within myocardial cells. Hyper-parathyroidism has been claimed to cause cardiac hypertrophy even in theabsence of hypercalcaemia.2 Serious cardiotoxicity seems to be unusualwith hyperparathyroidism, but serum concentrations should be reduced

before surgery if possible. Prompt surgical treatment may be neededfor severe hyperparathyroidism. Saline infusion and diuresis are recom-mended before the operation, usually with medical treatment aimedspecifically at reducing the serum calcium concentration.3 Experimentalevidence shows that nifedipine and verapamil may reduce serious cardio-toxicity induced by hypercalcaemia, but we do not know if this hasbeen used in association with surgery for hyperparathyroidism.-D ACHAMBERLAIN, cardiologist, N J A VAUGHAN, endocrinologist, Brighton

1 Fisch C. Relation of electrolyte disturbances to cardiac arrhythmias. Circulation 1973;47:408-19.2 Symons C, Fortune F, Greenbaum RA, Dandona P. Cardiac hypertrophy, hypertrophic

cardiomyopathy, and hyperparathyroidism-an association. BrHeartJ 1985;54:539-42.3 Wang C, Guyton SW. Hyperparathyroid crisis. Ann Surg 1979;190:782-90.

1018 BMJ VOLUME 298 15 APRIL 1989