The parents did not report any injury and presented their child only on the following day, in spite of severe pain. In the following sections, we will discuss the most common accidental and abuse-related (henceforth referred to as “inflicted,” to facilitate easier reading) trauma mechanisms and discuss the available evidence in the etiological classification.Ī distal femur fracture (short arrow) was diagnosed in a 16-month old toddler. The only differential diagnoses described in the literature are birth trauma (breech births and uncomplicated cesarean section) and treatment of club foot ( 21, 22). Kleinman describes the mechanism of trauma as combined tensile and torsional stress owing to violent tearing or leveraging ( 18). A follow-up radiograph is useful in this setting ( 18). The normal variant of a perichondral bone cuff can extend beyond the epiphyseal plate and can appear radiologically as a metaphyseal fracture. Periosteal hematomas or a raised periosteum are not usually detectable. They occur most commonly on the proximal and distal tibia and fibula, in the distal femur, and on the proximal humerus ( 2, 4). These have a particular position of importance because they are considered as almost pathognomonic for a non-accidental-that is, inflicted-origin ( 4, 18– 20). Because the fracture gap runs parallel to the x ray path, it is often only the peripheral parts of the fracture, which extend towards the diaphysis, that are identifiable and account for the fracture’s typical look of a corner fracture or a bucket handle fracture, depending on the x ray path. The injuries known in the English-language literature as classic metaphyseal lesions (CML) or metaphyseal corner fractures are also known as bucket handle fractures ( 17). “Awareness is the most critical component to making a diagnosis” ( 9). The objective of treating fractures therefore should be not only to achieve a medically and functionally flawless result, but also to trigger the necessary protection for the child. The opinion that is occasionally expressed-that having to present with the child in a hospital would constitute a salutary shock to parents and that the abuse would stop automatically afterwards-contradicts the available evidence and can be life-threatening for affected children. In our view, the responsibility for assessing the risk of recurrence lies with the youth welfare services. This association should be the guiding principle for the approach taken by physicians administering initial care. Even a single instance of loss of self control mostly arises within a system of promotive factors that will continue without intervention and therefore promotes recurrent behavior. The question if the resultant injury was intentionally inflicted or not does not play an important part in a child’s prognosis. By contrast, in our experience, intentional systematic torture of children is rarer. Furthermore, fractures can occur if (very young) children are insufficiently protected against dangers-that is, as a result of neglect. In our estimation, it is mostly outbursts of frustration, of feeling overstretched/unable to cope, or of anger in a parent or other carer that serve as triggers for abuse-often paired with the subsequent desire to want to undo the damage. We agree with the estimate of Herrmann et al., that “fractures (…) (signify) particularly violent abuse as they require substantial physical strength” ( 4). ( 8), 4 in 5 fatal cases of child abuse could have been prevented if action had been taken at the first presentation to the practice/hospital.Īfter soft tissue injuries, fractures are the second most common finding in physical abuse. According to a retrospective study by Jenny et al. The physicians who provide initial care in this setting have special responsibilities in the context of child abuse, because abuse is often recurrent and associated with high mortality ( 7). in a retrospective analysis from 1996 to 1998 found for Wales an incidence of abuse-related fractures of 56.8/100 000 in children younger than 6 months (95% confidence interval: ) and of 39.8/100 000 in children aged 6–11 months ( 6). In a recent study, the fractures in 31 (5.6%) of altogether 551 children with fractures (<36 months) were confirmed as caused by abuse (the proportion of fractures caused by accidents owing to neglect was not investigated) ( 5).
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