By The NAI Team
After bruising, fractures are the second most common type of non-accidental injury occurring in children. Therefore, medical professionals are obliged to be on the lookout for signs of child abuse when they treat children who have sustained broken bones especially when a child is non-mobile or the explanation is not consistent with the presented injury.
It is important to establish if there is any underlying medical condition which may pre-dispose a child to sustain fractures such as Osteogenisis Imperfecta, Vitamin D deficiency, Rickets, Osteopenia, Metabolic Disorders and Connective Tissue Disorders such as Ehlers Danlos Syndrome. This may mean that fractures occur as a result of less force than in a normal child without such conditions. It is also important to remember that there may be normal variants in children.
Unless a fracture is displaced (not in line) sometimes the presentation of a child can be non-specific with having sustained a fracture and thus only revealed on x-ray. Fractures may also not be obvious on an x-ray immediately after an incident in any event and thus follow-up x-rays will be required to see if the healing process has started which will then make dating of a fracture more accurate. It is known that it is more difficult to date certain fractures over others including metaphyseal fractures and skull fractures. Experienced paediatric radiologists are usually instructed to assist in such cases as they have the skill and up to date knowledge/ experience to date the fractures are easily as possible.
When a child presents with a fracture and there are concerns over the explanation provided then a skeletal survey may take place to ensure that there are no other injuries on the child concerned.
SOME OF THE DIFFERENT TYPES OF FRACTURES
A metaphyseal fracture refers to an injury to the metaphysis which is the growing plate at each end of a long bone. The metaphysis is not a bone but is a piece of cartilage which fuses together in adulthood.
The medical profession use multiple names to describe metaphyseal fractures including:
- Corner fractures
- Bucket fractures
- Metaphyseal lesions
These types of fractures can present on their own or alongside other injuries such as Non Accidental Head Injury. They are often seen as part of the triad of Shaken Baby Syndrome. The medical knowledge is that metaphyseal fractures are caused as a result of a pulling and/or twisting of a limb.
Metaphyseal fractures can be caused due to structural abnormalities, disease, infection etc. Metaphyseal fractures can be misdiagnosed as an injury resulting from child abuse because it is extremely uncommon for an infant to sustain this type of injury as a result of normal activity or even a fall.
Metaphyseal fractures are usually associated with non-accidental injury.
Children’s bones are softer and more flexible than adults as they are still growing; therefore, rather than suffer a complete break of a bone, they can get a greenstick fracture, where the bone simply bends and cracks on one side. Greenstick fractures can be difficult to diagnose.
A hairline fracture in a child is a fracture that does not go all the way through the bone, ie it can be described as a crack. Without medical attention the fracture may get worse.
Long Bone Fracture
The term ‘long bones’ is used to classify bones in the human body that have a length greater than their width. An example of a long bone is the femur.
If a child presents at hospital with a long bone fracture, doctors are trained to look out for irregularities in the account provided by the care giver or previous injuries. These type of fractures are strongly associated with abuse in children unless there is an adequate explanation. In conditions such as Osteogenesis Imperfecta and Ricketts you would usually see fractures of the Long Bones but rarely on the metaphysis.
Rib fractures are one of the most common types of fractures associated with child abuse. Whilst this fact makes it understandable why medical professionals and the children’s services need to fully investigation matters this provides little comfort to parents who are wrongly accused of causing the injury to their child. It is thought that Rib Fractures are caused by compression or squeezing of the ribs.
Sometimes Rib fracture occur In isolation to other injuries or in conjunction with other injuries. Just like any other fracture, it is important to establish if there is any underlying pre-disposition to the injury and also to consider if there are any normal variants.
A skull fracture can occur at any point on the skull. Professionals have to be careful when identifying skull fractures to make sure that they are not fissures or other abnormalities. Skull fractures are of concern to professionals in the absence of an adequate explanation as unless there is any underlying pre-disposition a skull fracture requires force which would involve some form of trauma.
Immobile children are not able to cause skull fractures to themselves.
When there is no adequate explanation which is accepted by the treating clinicians care proceedings may be issued and an expert is appointed by the Court who considers the explanation to see if it may be responsible for causing the injuries.
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