Evaluating Children with Fractures for Child Physical Abuse Abstract

FROM THE AMERICAN ACADEMY OF PEDIATRICS

Guidance for the Clinician in Rendering Pediatric Care

CLINICAL REPORT Evaluating Children With Fractures for Child Physical Abuse

Emalee G. Flaherty, MD, Jeannette M. Perez-Rossello, MD, Michael A. Levine, MD, William L. Hennrikus, MD, and the abstract AMERICAN ACADEMY OF PEDIATRICS COMMITTEE ON CHILD Fractures are common injuries caused by child abuse. Although the ABUSE AND NEGLECT, SECTION ON RADIOLOGY, SECTION ON ENDOCRINOLOGY, and SECTION ON ORTHOPAEDICS, and the consequences of failing to diagnose an abusive injury in a child SOCIETY FOR PEDIATRIC RADIOLOGY can be grave, incorrectly diagnosing child abuse in a child whose frac- KEY WORD tures have another etiology can be distressing for a family. The aim of fractures this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical dis- ABBREVIATIONS CML—classic metaphyseal lesions eases that predispose to fractures in infants and children. This CPR—cardiopulmonary resuscitation clinical report will aid physicians in developing an evidence-based dif- CT—computed tomography ferential diagnosis and performing the appropriate evaluation when OI—osteogenesis imperfect assessing a child with fractures. Pediatrics 2014;133:e477–e489 This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through INTRODUCTION a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any Fractures are the second most common injury caused by child physical commercial involvement in the development of the content of abuse; bruises are the most common injury.1 Failure to identify an this publication. injury caused by child abuse and to intervene appropriately may The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. place a child at risk for further abuse, with potentially permanent Variations, taking into account individual circumstances, may be consequences for the child.2–4 Physical abuse may not be considered appropriate. in the physician’s differential diagnosis of childhood injury because the caregiver may have intentionally altered the history to conceal the abuse.5 As a result, when fractures are initially evaluated, a diagnosis of child abuse may be missed.3 In children younger than 3 years, as many as 20% of fractures caused by abuse may be misdiagnosed initially as noninflicted or as attributable to other causes.3 In addition, fractures may be missed because radiography is performed before changes are obvious or the radiographic images are misread or misinterpreted.2 However, incorrectly diagnosing physical abuse in a child with noninflicted fractures has serious consequences for the child and www.pediatrics.org/cgi/doi/10.1542/peds.2013-3793 family. To identify child abuse as the cause of fractures, the physician doi:10.1542/peds.2013-3793 must take into consideration the history, the age of the child, the location All clinical reports from the American Academy of Pediatrics and type of fracture, the mechanism that causes the particular type of automatically expire 5 years after publication unless reaffirmed, fracture, and the presence of other injuries while also considering other revised, or retired at or before that time. possible causes. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2014 by the American Academy of Pediatrics DIFFERENTIAL DIAGNOSIS OF FRACTURES Trauma: Child Abuse Versus Noninflicted Injuries Fractures are a common childhood injury and account for between 8% and 12% of all pediatric injuries.6–8 In infants and toddlers, physical

PEDIATRICS Volume 133, Number 2, February 2014 e477 Downloaded from by guest on October 13, 2016 abuse is the cause of 12% to 20% of Fracture Specificity for Abuse in infants who have increased bone fractures.9 Although unintentional fragility.23–25 Fractures With High Specificity for fractures are much more common Abuse Cardiopulmonary resuscitation (CPR) than fractures caused by child abuse, has been proposed as a cause of rib As shown in Table 1, certain fractures the physician needs to remain aware fractures, but conventional CPR with 2 have high specificity for or strong as- of the possibility of inflicted injury. fingers of 1 hand rarely causes frac- sociation with child abuse, particularly Although some fracture types are 26,27 in infants, whereas others may have tures in children. Recent recom- highly suggestive of physical abuse, mendations that CPR be performed less specificity.21 Rib fractures in no pattern can exclude child abuse.10,11 using 2 hands encircling the rib cage Specifically, it is important to recog- infants, especially those situated post- eromedially, and the classic meta- have raised concerns that this tech- nize that any fracture, even fractures nique might cause rib fractures. An that are commonly noninflicted inju- physeal lesions of long bones, have high specificity for child abuse. Frac- analysis of infants who were discov- ries, can be caused by child abuse. ered during autopsy to have rib frac- Certain details that can help the tures of the scapula, spinous process, fi tures and had received 2-handed physician determine whether a frac- and sternum also have high speci city for abuse but are uncommon. chest compressions antemortem ture was caused by abuse rather suggested that 2-handed CPR is as- Rib fractures are highly suggestive of than unintentional injury include the sociated with anterior-lateral rib ’ child abuse. Most abusive rib fractures history, the childs age and de- fractures of the third to sixth ribs.28 result from anterior-posterior com- velopmental stage, the type and lo- In this small study, no posterior rib pression of the chest. For this reason, cation of the fracture, the age of the fractures were observed. The frac- rib fractures are frequently found in fracture, and an understanding of the tures in these infants were always infants who are held around the chest, mechanism that causes the particu- multiple, uniformly involved the squeezed, and shaken. Rib fractures lartypeoffracture.Thepresenceof fourth rib, and were sometimes bi- have high probability of being caused multiple fractures, fractures of dif- lateral. Additional research is needed by abuse.15,17,21 The positive predictive ferent ages or stages of healing, de- to examine the relationship between value of rib fractures for child abuse in lay in obtaining medical treatment, the 2-handed CPR technique and rib children younger than 3 years was and the presence of other injuries fractures. suspicious for abuse (eg, coexisting 95% in one retrospective study.22 Other injuries to the skin, internal organs, less common causes of rib fractures in Classic metaphyseal lesions (CMLs) fi or central nervous system) should infants include significant trauma also have high speci city for child alert the physician to possible child sustained during childbirth or a motor abuse when they occur during the fi 21,29 abuse. vehicle crash as well as minor trauma rst year of life. CMLs are the most common long bone fracture found in infants who die with evi- 30 Child’s Age and Development TABLE 1 Specificity of radiologic findings in dence of inflicted injury. CMLs are 19 The physician should consider the infants and toddlers planar fractures through the pri- child’s age and level of development. High specificitya mary spongiosa of the metaphysis. Approximately 80% of all fractures CMLs These fractures are caused when Rib fractures, especially posteromedial caused by child abuse occur in chil- torsional and tractional shearing Scapular fractures strains are applied across the met- dren younger than 18 months,12 and Spinous process fractures approximately one-quarter of fractures Sternal fractures aphysis, as may occur with vigorous Moderate specificity ’ in children younger than 1 year are pulling or twisting of an infant sex- Multiple fractures, especially bilateral – tremity.31 Fractures resembling caused by child abuse.1,9,13 15 Physical Fractures of different ages abuse is more likely to be the cause of Epiphyseal separations CMLs radiographically have been femoral fractures and humeral frac- Vertebral body fractures and subluxations reported after breech delivery32 and Digital fractures as a result of treatment of club- tures in children who are not yet Complex skull fractures 33 walking compared with children who Common, but low specificity foot. are ambulatory,15–18 and the percent- Subperiosteal new bone formation Depending on the projection of the Clavicular fractures age of fractures caused by abuse Long-bone shaft fractures radiograph, CMLs can have the ap- declines sharply after the child begins Linear skull fractures pearance of a corner or a bucket- to walk.9,19,20 a Highest specificity applies in infants. handle fracture. Acute injuries can

e478 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from by guest on October 13, 2016 FROM THE AMERICAN ACADEMY OF PEDIATRICS be difficult to visualize radiographi- to the bone, whereas spiral fractures down several steps and landing with 1 cally. CMLs commonly heal without are caused by torsion or twisting of leg folded or twisted underneath subperiosteal new bone formation or a long bone along its long axis. Obli- a child can lead to excessive torsional marginal sclerosis. They can heal que fractures are caused by a combi- loading of the femur and a spiral quickly and be undetectable on plain nation of bending and torsion loads.37 fracture.46 In ambulatory children, radiographs in 4 to 8 weeks.31 Torus or buckle fractures are the re- noninflicted femoral fractures have sult of compression from axial loading been described in children who fell Fractures With Moderate Specificity along the length of the bone. Although while running or who fell and landed for Abuse earlier studies suggested that spiral in a split-leg position.43 Although many children who have fractures should always raise suspi- A fracture of the humeral shaft in a child 12 been abused will have only a single cion for child abuse, more recent younger than 18 months has a high fracture,34 thepresenceofmultiple studies do not show that any partic- likelihood of having been caused by fractures, fractures of different ages ular fracture pattern can distinguish abuse.15,49,50 In contrast, supracondylar and/or stages of healing, and com- between abuse and nonabuse with fractures in ambulatory children are 16,38 plex skull fractures have moderate absolute certainty. usually noninflicted injuries resulting specificity for physical abuse. In ad- Falls are common in childhood.39 Short from short falls.15 dition, epiphyseal separations, verte- falls can cause fractures, but they Physicians should also be aware of bral body fractures, and digital rarely result in additional significant a particular mechanism reported to fractures have moderate specificity injury (eg, neurologic injury).11,40–42 In produce a noninflicted spiral-oblique for abuse. The presence of multiple a retrospective study of short falls, fracture of the humerus in 1 case fractures or fractures of different parents reported that 40% of the report.51 When the young infant was ages can be signs of bone fragility children before 2 years of age had rolled from the prone position to the but should also evoke consideration suffered at least 1 fall from a height of supine while the child’s arm is ex- of child abuse. Besides the predictive between 6 inches and 4 feet. Approx- tended, the torsion and stress placed value of the particular pattern of imately one-quarter of these children on the extended arm appeared to fractures, many other factors, such suffered an injury; bruises were the cause a spiral-oblique fracture of the as the history and the child’sage, most common injury observed.43 midshaft of the humerus. must be considered when de- The femur, humerus, and tibia are the Linear skull fractures of the parietal termining whether the injury was most common long bones to be in- bone are the most common skull fl in icted. jured by child abuse.1,34 Femoral fracture among young children, usu- fractures in the nonambulatory child ally children younger than 1 year.13 A Common Fractures With Low are more likely caused by child short fall from several feet onto Specificity for Child Abuse abuse, whereas these fractures in a hard surface can cause a linear, Long bone fractures (other than CMLs), ambulatory children are most com- nondiastatic skull fracture.19,52 The – linear skull fractures, clavicle fractures, monly noninflicted.10,16,43 45 majority of linear skull fractures are and isolated findings of subperiosteal Certain femur fractures may occur as not inflicted.53 By contrast, complex or new bone formation have low speci- a result of a noninflicted injury in young bilateral skull fractures are typical of ficity for child abuse. In contrast, the children. Several studies have demon- nonaccidental trauma. single long bone diaphyseal fracture is strated that a short fall to the knee may the most common fracture pattern produce a torus or impacted transverse Syndromes, Metabolic Disorders, identified in abused children.1,13,34 fracture of the distal femoral meta- Systemic Disease An understanding of the extent and diaphysis.46,47 Oblique distal femur met- Preexisting medical conditions and type of load that is necessary to cause aphyseal fractures have been reported bone disease may make a child’s a particular long bone fracture can in children playing in a stationary ac- bones more vulnerable to fracture. help to determine whether a specific tivity center, such as an Exersaucer Some conditions may manifest skele- fracture is consistent with the injury (Evenflo, Picqua, OH).48 tal changes, such as metaphyseal ir- described by the caregiver.35,36 Trans- In both ambulatory and nonambulatory regularity and subperiosteal new verse fractures of the long bones are children, under some circumstances, bone formation. These entities should caused by the application of a bending falls on a stairway can cause a spiral be considered in the differential di- load in a direction that is perpendicular femoral fracture. For example, a fall agnosis of childhood fractures.

PEDIATRICS Volume 133, Number 2, February 2014 e479 Downloaded from by guest on October 13, 2016 Osteogenesis Imperfecta long bones. It is unusual to have mul- Although osteopenia of prematurity Osteogenesis imperfecta (OI) is a het- tiple long bone fractures or rib frac- may make the infant more vulnerable erogeneous family of diseases, usually tures, particularly in infancy, without to fracture, preterm infants are also at caused by heterozygous mutations of other clinical and radiographic evi- an increased risk of abuse.68 the genes COL1A1 and COL1A2,54 but dence of OI.57,58 mutations in these and other genes OI has been misdiagnosed as child Vitamin D Deficiency Rickets can cause autosomal recessive forms abuse.59 On the other hand, OI is often Suboptimal vitamin D concentrations of OI. The COL1A1 and COL1A2 genes suggested as the cause of fractures in and rickets have been proposed as encode the chains of type I collagen, children who have been abused. If causes of fractures in infants.69 Vitamin which forms the structural framework fractures continue to occur when Dinsufficiency in otherwise healthy of bone. Although it is a genetic dis- a child is placed in a protective envi- infants and toddlers is common. Ap- order, many children have de novo ronment, a more thorough evaluation proximately 40% of infants and tod- mutations or autosomal-recessive dis- for an underlying bone disease is dlers aged 8 to 24 months in an urban ease and no family history of bone needed. Child abuse is more common clinic had laboratory evidence of vita- fragility. In addition, the presentation of than OI,60 and children with OI and min D insufficiency (serum concen- the disease within affected members other metabolic or genetic conditions trations of 25-hydroxyvitamin D of ≤30 of the same family can be quite vari- may also be abused.61,62 ng/mL).70 Prolonged breastfeeding able. Phenotypic expression of the without vitamin D supplementation disease depends on the nature of the Preterm Birth was a critical factor that placed these mutation, its relative abundance at- Preterm infants have decreased bone infants at risk, although increased skin tributable to mosaicism, and its ex- mineralization at birth, but after the pigmentation and/or lack of sunlight pression in target tissues.55 Some first year of life, bone density nor- exposure may also have contributed. types of OI involve reduced production malizes.63,64 Osteopenia of prematurity Rickets is characterized by de- of collagen, and the symptoms resolve has been well described as a compli- mineralization, loss of the zone of or lessen after puberty.56 Table 2 lists cation in low birth weight infants.65 provisional calcification, widening the various signs and symptoms that Infants born at less than 28 weeks’ and irregularity of the physis, and can be present in a case of OI. gestation or who weigh less than 1500 fraying and cupping of the meta- The diagnosis of OI is often suggested g at birth are particularly vulnerable. physis.71 Despite the high prevalence by a family history of fractures, short Osteopenia of prematurity is multi- of vitamin D insufficiency in infants stature, blue sclera, poor dentition, factorial. Infants are also at risk if and toddlers, rickets is uncommon.72 and radiographic evidence of low bone they receive prolonged (for 4 or more density or osteopenia. The fractures weeks) total parenteral nutrition, have The claim that vitamin D deficiency or are most commonly transverse in bronchopulmonary dysplasia, and/or insufficiency causes skeletal lesions nature, occurring in the shafts of the have received a prolonged course of that lead to the incorrect diagnosis of diuretics or steroids.66 Osteopenia child abuse in infants is not sup- commonly presents between 6 and 12 TABLE 2 Characteristics of Osteogenesis ported in the literature. A systematic Imperfecta weeks of life. Osteopenia of pre- clinical, laboratory, and radiologic maturity can be ameliorated if infants Fragile bones with few, some, or many of the assessment should exclude that following findings: are monitored closely and receive the possibility.73–75 Schilling et al found Poor linear growth nutritional and mineral supplementa- no difference in serum concen- Macrocephaly tion initiated in the NICU. Triangular-shaped face trations of 25-hydroxyvitamin D in Blue sclerae Fractures associated with osteopenia of young children with fractures suspi- Hearing impairment as a result of otosclerosis prematurity usually occur in the first cious for abuse and noninflicted Hypoplastic, translucent, carious, late-erupting, year of life.67 Rib fractures are typically fractures.76 Vitamin D insufficiency or discolored teeth Easy bruisability encountered incidentally, whereas long was not associated with multiple Inguinal and/or umbilical hernias bone fractures commonly present with fractures, in particular rib fractures Limb deformities swelling of the extremity. Osteopenia of or CMLs, the high specificity indica- Hyperextensible joints Scoliosis and/or kyphosis prematurity can be associated with tors of abuse. Perez-Rossello et al Wormian bones of the skull rickets, and in such cases, meta- studied radiographs of 40 healthy Demineralized bones physeal irregularities may be present. older infants and toddlers with

e480 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from by guest on October 13, 2016 FROM THE AMERICAN ACADEMY OF PEDIATRICS vitamin D insufficiency and deficiency inflicted and noninflicted fractures oc- months of age, because fetal copper and concluded that radiographic ra- curring in these children. At the same stores are sufficient for this length chitic changes were uncommon and time, children with disabilities are at an of time. In addition, human milk and very mild. In this population, the increased risk of being maltreated.82–84 formula contain sufficient copper to reported fracture prevalence was When multiple or recurrent fractures prevent deficiency. Psychomotor re- zero.72 occur in a disabled child, a trial change tardation, hypotonia, hypopigmentation, In a study of 45 young children with in caregivers may be indicated to de- pallor, and a sideroblastic anemia are radiographic evidence of rickets, termine whether the fractures can be some of the characteristic findings of investigators found that fractures oc- prevented. This is an extreme in- copper deficiency in infants. Radiologic curred only in those infants and tod- tervention and should be reserved for changes that should lead to further dlers who were mobile.77 Fractures unusual circumstances.63 evaluation for possible deficiency were seen in 17.5% of the children, include cupping and fraying of the and these children were 8 to 19 Scurvy metaphyses, sickle-shaped metaphyseal spurs, significant demineralization, and months of age. The fractures involved Scurvy is caused by insufficient intake subperiosteal new bone formation. long bones, anterior-lateral and lat- of vitamin C, which is important for the eral ribs, and metatarsal and meta- synthesis of collagen. Although rare physeal regions. The metaphyseal today because formula, human milk, Menkes Disease fractures occurred closer to the di- fruits, and vegetables contain vitamin Menkes disease, also known as aphysis in the background of florid C, scurvy may develop in older infants Menkes kinky hair syndrome, is a rare metaphyseal rachitic changes and and children given exclusively cow congenital defect of copper metabo- did not resemble the juxtaphyseal milk without vitamin supplementation lism.90 Menkes disease is an X-linked corner or bucket handle pattern of and in children who eat no foods recessive condition and occurs only in the CML. In infant fatalities in which containing vitamin C.85–87 Although boys. Although it has many of the abuse is suspected, rachitic changes scurvy can result in metaphyseal features of dietary copper deficiency, appear to be rare histologically.78 changes similar to those seen with anemia is not associated with Menkes child abuse, other characteristic bone disease. Metaphyseal fragmentation Osteomyelitis changes, including osteopenia, in- and subperiosteal new bone forma- Osteomyelitisininfantscanpresentas creased sclerosis of the zones of tion may be observed on radiographs, multiple metaphyseal irregularities provisional calcification, dense epiph- and the findings may be difficult to potentially resembling CMLs.79 Typically, yseal rings, and extensive calcification distinguish from fractures caused by the lesions become progressively lytic of subperiosteal and soft tissue hem- abuse.91 Other signs of Menkes dis- and sclerotic with substantial sub- orrhages, will point to the diagnosis ease include sparse, kinky hair, cal- periosteal new bone formation. Other of scurvy. varial wormian bones, anterior rib signs of infection are often present, flaring, failure to thrive, and de- such as fever, increased erythrocyte Copper Deficiency velopmental delay. A characteristic finding is tortuous cerebral vessels. sedimentation rate, elevated C-reactive Copper plays a role in cartilage for- Intracranial hemorrhage can occur in protein concentration, and elevated mation. Copper deficiency is a rare Menkes disease but has not been white blood cell count. condition that may be complicated by reported in infants with copper de- bone fractures. Preterm infants are ficiency. Fractures Secondary to born with lower stores of copper than Demineralization From Disuse term infants, because copper is ac- Any child with a severe disability that cumulated at a faster rate during the Systemic Disease limits or prevents ambulation can be at last trimester.88 Copper insufficiency Chronic renal disease affects bone risk for fractures secondary to disuse maybeobservedinchildrenwith metabolism because children with demineralization, even with normal severe nutritional disorders, for ex- chronic renal disease may develop handling.80,81 Thefracturesareusually ample, liver failure or short gut syn- a metabolic acidosis that interferes diaphyseal rather than CMLs. Often, drome.89 This deficiency is not likely with vitamin D metabolism. Chronic these fractures occur during physical to be observed in full-term children renal disease can cause renal osteo- therapy and range-of-motion exercises. younger than 6 months of age or dystrophy resulting in the same ra- It can be difficult to distinguish between preterm infants younger than 2.5 diographic changes as nutritional

PEDIATRICS Volume 133, Number 2, February 2014 e481 Downloaded from by guest on October 13, 2016 rickets. Because chronic liver disease for infants. He relied on the mother’s some swelling, pain, or other signs, (eg, biliary atresia) interferes with vi- history of decreased fetal movements such as decreased use of the ex- tamin D metabolism, such children may and provided no independent mea- tremity, suggesting a fracture.100,101 be at an increased risk of fractures. surements of those movements. Pala- Some children, however, will have Fanconi syndrome, hypophosphatasia, cios and Rodriguez found no evidence minimal external signs of injury.102 hypophosphatemic (vitamin D resistant) that oligohydramnios affects bone mass The absence of any history of injury, rickets, hyperparathyroidism, and renal of the fetus, probably because fetal a vague description of the event, tubular acidosis also cause clinical movement is only restricted in the last a delay in seeking care, the absence variants of rickets. trimester of pregnancy by oligohy- of an explanation for an injury par- dramnios and because the mechanical ticularly in a nonambulatory child, or loading on the bones stimulating bone an inconsistent explanation should Temporary Brittle Bone Disease formation is conserved.99 increase the physician’s concern that Hypothesis an injury was caused by child abuse Physicians should be aware of alter- (see Table 3).13,16 native diagnoses that are unsupported Medical Evaluation by research but are sometimes sug- History of Present Illness Past Medical History gested when an infant has unexplained The past medical history is important fractures. In 1993, Paterson proposed It is essential to obtain a detailed history to determine how an injury oc- and should include details about the that some infants may be born with ’ curred. If an injury in a nonverbal child mothers pregnancy. If the child was bones that are temporarily more born preterm, the infant’s bone min- fragile or vulnerable to fracture in the was witnessed, the caregiver should be able to provide details about the child’s eral content may be reduced, and the context of normal handling, which he infant may be at risk for fracture. A “ activity and position before an injury called temporary brittle bone dis- history of total parental nutrition, ”92 and the child’s final position and loca- ease. Paterson suggested that hepatobiliary disease, diuretic ther- fi tion after the injury occurred.46 Verbal some trace element de ciency, such apy, hypercalciuria, or corticosteroids as copper or a transient collagen im- children with concerning fractures should be interviewed apart from may make the bones of a low birth maturity, caused the disease but pro- weight infant even more vulnerable to fi fi caregivers and ideally by a professional vided no scienti c data that con rmed fracture. In addition, chronic diseases, fi who is skilled in forensic interviewing. his hypotheses and offered no speci c such as renal insufficiency or meta- fi test that con rmed temporary brittle A comparison of the histories provided bolic acidosis, malabsorption, cere- 61 bone disease. Subsequent studies did by caregivers of children with non- bral palsy or other neuromuscular fl not support his hypotheses, and his in icted femoral fractures and by disorders, genetic diseases that affect 57,93–95 case analysis has been refuted. caregivers of children whose injuries skeletal development, or any illness Miller hypothesized that temporary were caused by abuse is instructive. that limits mobility, may affect bone brittle bone disease is a result of fetal When an injury was caused by abuse, strength. A thorough dietary history immobilization or intrauterine con- the caregiver provided either no his- and history of medications that can finement that leads to transient bone tory of an injury or related a history of loss or osteopenia.96,97 In support of a low-energy event. By contrast, 29% of his hypothesis, he reported that 95% the caregivers of children with non- TABLE 3 When Is a Fracture Suspicious for Child Abuse? of 21 infants with multiple unexplained inflicted injuries provided some high- fractures had decreased fetal move- energy explanation, such as a motor • No history of injury • History of injury not plausible—mechanism ments, according to their mothers.97,98 vehicle collision or that the child fell 16 described not consistent with the type of Although he used bone densitometry in from a height. Most of the low- fracture, the energy load needed to cause the each patient as a basis for his con- energy mechanisms provided for the fracture, or the severity of the injury clusions, none of the patients had had noninflicted injuries involved falls in- • Inconsistent histories or changing histories cluding stair falls and siblings landing provided by caregiver bone densitometry performed at the • Fracture in a nonambulatory child 16,46 time of the fracture. The testing was on the femur during play. • Fracture of high specificity for child abuse (eg, performed 8 to 21 weeks later, and no The child’s response to the event may rib fractures) • Multiple fractures infantsweretestedbefore5monthsof also provide important clues about • Fractures of different ages age. In addition, bone densitometry the etiology. The majority of children • Other injuries suspicious for child abuse standards have not been established with long bone fractures will have • Delay in seeking care for an injury

e482 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from by guest on October 13, 2016 FROM THE AMERICAN ACADEMY OF PEDIATRICS predispose to fractures are impor- neck, or trunk should raise suspicion type I collagen and may identify the tant. The physician should inquire for child abuse.105,106 The child should mutation to guide testing of other about previous injuries including be examined for other injuries caused family members.107 Some of the less bruises and determine the child’s de- by child abuse, in addition to signs of common forms of OI are OI types IIB velopmental abilities, because chil- other medical conditions associated and VII, CRTAP;OItypeVI,FKBP10;OI dren who are not yet mobile are much with bone fragility. Blue sclerae are type VIII, LEPRE1;OItypeIX,PPIB;OItype more likely to have fractures caused seen in certain types of OI. Sparse, X, SERPINH1; OI type XI, SP7; OI type XII, by abuse. kinky hair is associated with Menkes SERPINF1; and OI type XIII, BMP1. DNA disease. Dentinogenesis imperfecta is sequencing can be performed using Family History occasionally identified in older chil- genomic DNA isolated from peripheral A family history of multiple fractures, dren with OI. blood mononuclear cells or even sa- early-onset hearing loss, abnormally liva, whereas the biochemical analysis of type I collagen requires a skin bi- developed dentition, blue sclera, and Laboratory Evaluation short stature should suggest the opsy. Doing both DNA analysis and The clinical evaluation should guide possibility of OI. skin biopsy is not indicated in most the laboratory evaluation. In children cases. Consultation with a pediatric with fractures suspicious for abuse, Social History geneticist may be helpful in deciding serum calcium, phosphorus, and al- which children to test and which test The physician should obtain a com- kaline phosphatase should be reviewed, to order.108 plete psychosocial history, including although alkaline phosphatase may be asking who lives in the home and who elevated with healing fractures. The has provided care for the child. The physician should consider checking Imaging Approach history should inquire about intimate serum concentrations of parathyroid Children younger than 2 years with partner violence, substance abuse hormone and 25-hydroxyvitamin D, as fractures suspicious for child abuse including drugs and alcohol, mental well as urinary calcium excretion (eg, should have a radiographic skeletal illness, and previous involvement with random urinary calcium/creatinine survey to look for other bone injuries child protective services and/or law ratio) in all young children with or osseous abnormalities.109 Addi- enforcement. fractures concerning for abuse, but tional fractures are identified in ap- these levels should certainly be proximately 10% of skeletal surveys, Physical Examination assessed if there is radiographic ev- with higher yields in infants.110 Skeletal The child should have a comprehensive idence of osteopenia or metabolic surveys may be appropriate in some physical examination, and the growth bone disease. Screening for abdomi- children between ages 2 and 5 years, chart should be carefully reviewed. nal trauma with liver function studies depending on the clinical suspicion Abnormal weight may suggest neglect as well as amylase and lipase con- of abuse. If specific clinical findings or endocrine or metabolic disorders. centration should be performed when indicate an injury at a particular Any signs or symptoms of fractures, severe or multiple injuries are iden- site, imaging of that area should such as swelling, limitation of motion, tified. A urinalysis should be per- be obtained regardless of the child’s and point tenderness should be formed to screen for occult blood. age. documented. The physician should do Serum copper, vitamin C, and ceru- The American College of Radiology has a complete skin examination to look loplasmin concentrations should be developed specific practice guidelines for bruises and other skin findings considered if the child is at risk for for skeletal surveys in children.111 because bruises are the most common scurvy or copper deficiency and has Twenty-one images are obtained, in- injury caused by child abuse. The radiographic findings that include cluding frontal images of the appen- majority of children with fractures do metaphyseal abnormalities. dicular skeleton, frontal and lateral not have bruising associated with the If OI is suspected, sequence analysis views of the axial skeleton, and obli- fracture; the presence or absence of of the COL1A1 and COL1A2 genes that que views of the chest. Oblique views such bruising does not help to de- are associated with 90% of cases of of the chest have been shown to in- termine which fractures are caused by OI as well as other genes associated crease the sensitivity, specificity, and child abuse.103,104 Bruising in a child with less common autosomal- accuracy of the identification of rib who is not yet cruising or bruising in recessive forms of OI may be more fractures.112 A full 4 skull series should unusual locations, such as the ears, sensitive than biochemical tests of be obtained if there are concerns of

PEDIATRICS Volume 133, Number 2, February 2014 e483 Downloaded from by guest on October 13, 2016 head injury. Computed tomography (CT) the specific clinical indicators of of equivocal or negative skeletal sur- 3-dimensional models are valuable abuse.109 veys when there is high clinical suspi- 18 adjuncts to the radiographs and have Because brain injuries are often occult, cion of abuse. If available, a F-NaF the potential to replace the skull se- head imaging should be considered for positron emission tomography bone ries.113 This has not been studied sys- any child younger than 1 year with scan has better contrast and spatial 99m tematically in this context, however. a fracture suspicious for abuse.121 Im- resolution than Tc-labeled methy- Because lateral views of the extremities aging studies may help clarify whether lene diphosphonate.120 increase yield, some authors suggest the child has been abused, provide Although bone densitometry by dual- that these views be included in the further support for a diagnosis of child energy x-ray absorptiometry is useful imaging protocol.114 Fractures may be abuse, and identify other injuries that to predict bone fragility and fracture missed if the guidelines are not fol- require treatment. Additional imaging risk in older adults, interpretation of lowed or if the images are of poor may be needed if the child has signs or bone densitometry in children and quality.115 A repeat skeletal survey symptoms of chest, abdominal, or neck adolescents is more problematic.126 In should be performed approximately 2 injury. adults, bone densitometry is inter- to 3 weeks after the initial skeletal Chest CT can identify rib fractures that preted using T scores, which describe survey if child abuse is strongly sus- are not seen on chest radiographs.122 the number of SDs above or below the 109,116 pected. The follow-up examination CT is particularly useful in detecting average peak bone mass for a gender- may identify fractures not seen on the anterior rib fractures and rib frac- and race-adjusted reference group of initial skeletal survey, can clarify un- tures at all stages of healing—early normal subjects. Because peak bone fi fi certain ndings identi ed by the initial subacute, subacute, and old fractures. mass is not achieved until approxi- skeletal survey, and improves both Although CT may be more sensitive in mately 30 years of age, in children, fi sensitivity and speci city of the skeletal identifying these injuries, a chest CT z scores must be used to express bone survey.116,117 In one study, 13 of 19 exposes the child to significantly more density, because z scores express the ’ fractures found on the follow-up ex- radiation than chest radiography. Ev- childs bone mineral density as a func- amination were not seen on the initial ery effort should be made to reduce tion of SDs above or below the average series.116 The number of images on the children’s exposure to radiation while for an age- and gender-matched norm 127 follow-up examination may be limited at the same time considering the risk control population. In addition, be- fl to 15 views by omitting the views of the to the child if abuse is not identi- cause bone size in uences dual-energy 118 x-ray absorptiometry, z scores must skull, pelvis, and lateral spine. fied.123 Therefore, selective application also be adjusted for height z scores.128 Radiography may assist in assessing of this technique in certain clinical The International Society for Clinical the approximate time when an injury settings is appropriate. occurred because long bone fractures Densitometry recommends that the Other modalities may become available diagnosis of osteoporosis in childhood heal following a particular sequence.119 in the future that will provide more should not be made on the basis of low If the healing pattern is not consistent accurate identification of skeletal inju- with the explanation provided, the bone mass alone but should also in- ries. Whole-body short tau inverse re- clude a clinically significant history accuracy of the explanation should be covery imaging, a magnetic resonance questioned. of low-impact fracture. The recom- imaging (MRI) technique, may identify mendations currently apply to chil- Bone scintigraphy may be used to rib fractures not recognized on the dren 5 years and older, although complement the skeletal survey but radiographic skeletal survey.124 In reference data are available for chil- should not be the sole method of a study of 21 infants with suspected dren as young as 3 years.129,130 Un- identifying fractures in infants. Al- abuse, whole-body MRI at 1.5-Tesla was fortunately, there are limited reference though it has high overall sensitivity, it insensitive in the detection of CMLs data for the young, nonverbal child fi lacks speci city for fracture detection and rib fractures. In some cases, who is most at risk for suffering frac- and may fail to identify CMLs and skull whole-body MRI identified soft tissue tures caused by child abuse. fractures.109,119,120 Scintigraphy does edema and joint effusions that led to have high sensitivity for identifying rib the identification of skeletal injuries fractures, which can be difficult to with additional radiographs.125 Bone Evaluation of Siblings detect before healing. In toddlers and scintigraphy with 18F-sodium fluoride Siblings, especially twins, and other older children, the use of bone scin- positron emission tomography (18F-NaF young household members of children tigraphy or skeletal survey depends on PET) bone scan may be useful in cases who have been physically abused

e484 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from by guest on October 13, 2016 FROM THE AMERICAN ACADEMY OF PEDIATRICS should be evaluated for maltreat- groups and across all racial and ethnic Emalee G. Flaherty, MD, FAAP ment.131 In a study of 795 siblings in groups. Many of these diagnoses are John M. Leventhal, MD, FAAP James L. Lukefahr, MD, FAAP 400 households of a child who had complex. If a physician is uncertain Robert D. Sege MD, PhD, FAAP been abused or neglected, all sib- about how to evaluate an injury or if lings in 37% of households and some they should suspect a fracture was LIAISONS siblings in 20% of households had caused by child abuse, they should Harriet MacMillan, MD – American Academy of suffered some form of maltreat- consult a child abuse pediatrician Child and Adolescent Psychiatry Catherine M. Nolan, MSW, ACSW – Administration ment.132 In this study, which included or multidisciplinary child abuse team for Children, Youth, and Families all manifestations of maltreatment, to assist in the evaluation, particu- Linda Anne Valley, PhD – Centers for Disease siblings were found to be more at larly if the child is nonambulatory Control and Prevention risk for maltreatment if the index or younger than 1 year of age.134 In child suffered moderate or severe certain circumstances, the physician STAFF maltreatment. In addition to a careful will need to consult an orthopedist, Tammy Piazza Hurley evaluation, imaging should be consid- endocrinologist, geneticist, or other ered for any siblings younger than 2 subspecialists. SECTION ON RADIOLOGY EXECUTIVE – years, especially if there are signs of All US states, commonwealths, and COMMITTEE, 2012 2013 abuse. Christopher I. Cassady, MD, FAAP, Chairperson territories have mandatory reporting Dorothy I. Bulas, MD, FAAP requirements for physicians and John A. Cassese, MD, FAAP DIAGNOSIS other health care providers when Amy R. Mehollin-Ray, MD, FAAP child abuse is suspected. Physicians Maria-Gisela Mercado-Deane, MD, FAAP When evaluating a child with a frac- Sarah Sarvis Milla, MD, FAAP ture, physicians must take a careful should be aware of and comply with the reporting requirements of their history of any injury event and STAFF then determine whether the mechan- state. Typically, the standard for Vivian Thorne ism described and the severity and making a report is when the reporter “suspects” or “has reason to believe” timing are consistent with the injury SECTION ON ENDOCRINOLOGY identiﬁed (see Table 3).133 They must that a child has been abused or EXECUTIVE COMMITTEE, 2012–2103 consider and evaluate for possible di- neglected. Sometimes determining Irene N. Sills, MD, FAAP, Chairperson “ ” agnoses in addition to other signs or whether that reasonable belief or Clifford A. Bloch, MD, FAAP “ ” Samuel J. Casella, MD, MSc, FAAP symptoms of child abuse. A careful reasonable suspicion standard has been met can be nuanced and com- Joyce M. Lee, MD, FAAP evaluation for other injuries is im- Jane Lockwood Lynch, MD, FAAP portant because the presence of ad- plex. The physician should keep in Kupper A. Wintergerst, MD, FAAP ditional injuries that are associated mind that incontrovertible proof of with child abuse increases the likeli- abuse or neglect is not required by STAFF hood that a particular fracture was state statutes, and there may be Laura Laskosz, MPH inﬂicted.16,43 It is important to re- cases in which it is reasonable to member that even if a child has an consult with a child abuse pediatri- SECTION ON ORTHOPEDICS EXECUTIVE underlying disorder or disability that cian about whether a report should COMMITTEE, 2012–2013 could increase the likelihood of be made. Richard M. Schwend, MD, FAAP, Chairperson J. Eric Gordon, MD, FAAP a fracture, the child may also have Norman Y. Otsuka, MD, FAAP been abused because children with LEAD AUTHOR Ellen M. Raney, MD, FAAP disabilities and other special health Emalee G. Flaherty, MD, FAAP Brian A. Shaw, MD, FAAP care needs are at increased risk of Brian G. Smith, MD, FAAP Lawrence Wells, MD, FAAP child abuse.83,84 Physicians should COMMITTEE ON CHILD ABUSE AND Paul W. Esposito, MD, USBJD Liaison keep an open mind to the possibility of NEGLECT, 2012–2013 abuse and remember that child Cindy W. Christian, MD, FAAP, Chairperson STAFF abuse occurs in all socioeconomic James E. Crawford-Jakubiak, MD, FAAP Niccole Alexander, MPP

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Evaluating Children With Fractures for Child Physical Abuse Emalee G. Flaherty, Jeannette M. Perez-Rossello, Michael A. Levine, William L. Hennrikus, and the AMERICAN ACADEMY OF PEDIATRICS COMMITTEE ON CHILD ABUSE AND NEGLECT, SECTION ON RADIOLOGY, SECTION ON ENDOCRINOLOGY, SECTION ON ORTHOPAEDICS and the SOCIETY FOR PEDIATRIC RADIOLOGY Pediatrics 2014;133;e477; originally published online January 27, 2014; DOI: 10.1542/peds.2013-3793 Updated Information & including high resolution figures, can be found at: Services /content/133/2/e477.full.html References This article cites 125 articles, 33 of which can be accessed free at: /content/133/2/e477.full.html#ref-list-1 Citations This article has been cited by 7 HighWire-hosted articles: /content/133/2/e477.full.html#related-urls Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Committee on Child Abuse and Neglect /cgi/collection/committee_on_child_abuse_and_neglect Section on Endocrinology /cgi/collection/section_on_endocrinology Section on Radiology /cgi/collection/section_on_radiology Injury, Violence & Poison Prevention /cgi/collection/injury_violence_-_poison_prevention_sub Child Abuse and Neglect /cgi/collection/child_abuse_neglect_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: /site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: /site/misc/reprints.xhtml

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