The very thought of an infant with an intentional trauma makes me
so upset, that I must preface this answer with this statement: If you
know someone who is abusing a child or infant, you must report it at
once. The child must have appropriate medical care, and the abuser
needs serious counseling. Please note I am not accusing anyone of
abuse, simply advising you that IF this is occurring to someone you
know, you must intervene, for the good of all involved parties.
?Counseling or an intervention of some type for the parents is
mandatory. In some cases, the child may be temporarily or permanently
removed from the home to prevent further danger. Life-threatening
abuse, or abuse resulting in permanent damage to the infant or child,
may result in legal action.
Counseling, including play therapy, is also necessary for abused
children over age 2. Failure to help the child deal with the fear and
pain resulting from abuse by adults, who should be trusted figures,
can lead to significant psychological problems, such as post traumatic
stress disorder (PTSD).
All states require that you report any known or suspected child abuse.
Call the police and Child Protection Services.?
Now, on to your answer. It can be difficult to determine if a
fracture is intentional or accidental, however doctors and
radiologists have techniques that may lead them to suspect abuse,
depending on the angle of the fracture, the age, and any other marks
they may find. Many doctors will consider any fracture in an infant as
suspicious. (Every hospital I?ve worked in regarded an infant with a
fracture as suspicious) An x-ray, even years later, can reveal old
fractures, so avoiding treatment to escape detection of abuse is a
double whammy to the child. Even if medical personnel are suspicious,
further testing, a complete medical history and discussions with care
givers can help rule out abuse.
?The skeletal system may be injured in situations of child abuse or as
a result of everyday activities. All fractures must be interpreted in
the context of the child's developmental ability and the history of
injury. For example, a transverse long-bone fracture in a
three-month-old child is highly suspicious for physical abuse but may
be unremarkable in an eight-year-old child. While any type of fracture
can be the result of child abuse, certain fractures are much more
specific for nonaccidental trauma. Fractures involving parts of the
skeletal system or caused by mechanisms of injury unlikely to be from
accidental trauma should be viewed with suspicion.? *** Warning-There
are some graphic, heartbreaking pictures on this site.
?Several of these disorders may be distinguished from nonaccidental
trauma by the other physical signs of the syndrome or by a natural
history of the skin lesion that differs from that expected for an
?Reports of child abuse are increasing as the medical profession gains
experience in recognizing the signs and symptoms of physical abuse.
Anyone involved in the care of children is likely to see children who
have been physically abused. In 1996, approximately 1 million children
were confirmed to be victims of maltreatment, and 1,185 children died
from their injuries.3?
?The physician is mandated to report any suspected abuse to the state
child protective services agency.
In the face of these new and often unaccustomed roles, hostile
families may challenge physicians when the possibility of physical
abuse is broached. Preconceived ideas regarding racial, cultural or
economic norms as well as the strong feelings elicited when children
may have been intentionally injured are confounding factors
complicating the evaluation of suspected child abuse.?
?Children are commonly injured accidentally, and a history of
age-appropriate injury, not witnessed, should not by itself raise the
suspicion of child abuse. However, injury resulting from inappropriate
supervision may raise the issue of neglect, a form of child abuse.
When the patient's injuries are attributed to another child, the other
child's developmental ability must be considered.?
?The shape and position of a fracture on X-ray may help orthopaedic
surgeons to decide if an injury is from abuse or from an accident. For
child abuse, doctors use a special series of x-rays called the
skeletal survey. These x-rays can show fractures in young children who
are not able to talk about how their injuries happened. Doctors can
also use bone scans with radioactive tracers to find injured bone if
this kind of detail is needed.?
?Skin lesions (bruises, cuts, burns, etc.) are the most common
symptoms of child abuse. Fractures are the second most common child
?Fractures are the second most common injury resulting from child
abuse and are often indicative of escalating violence. The Classic
Metaphyseal Lesion (CML), also known as the corner, or bucket-handle
fracture, is reported to be highly associated with abusive trauma,
although the pathophysiology and biomechanics associated with this
fracture type are currently unknown.
When a young child or infant presents with a fracture, a
determination must be made: how much force did it take to cause this
injury and could the scenario provided generate the level of force
needed to cause the fracture? Is normal bone present or are there
factors that might alter fracture threshold? An inaccurate assessment
can result in an abused child being placed back into an unsafe
environment, where there is an 80% chance of re-injury and a 10-50%
chance of mortality. Conversely, innocent families may be investigated
for child abuse and non-abused children may be placed into foster
care. Differentiating between accidental and abusive fractures however
can be extremely difficult. A current lack of biomechanical
understanding of fractures in immature bone and the lack of an
objective tool for evaluating bone strength and likelihood of fracture
in children makes this determine more difficult.?
?What types of physical abuse are most common?
Soft tissue injuries such as hematomas, abrasions, and burns are the
most common presentations of physical abuse. Accidental soft tissue
injuries tend to be distributed over bony prominences, especially
forehead, knees, shins, and elbows. Inflicted soft tissue injuries, in
contrast, most commonly involve the soft tissues of the head and neck,
buttocks, genitals, as well as the trunk and hands. Inflicted injury
must be strongly considered if the reported mechanism doesn?t
correlate with the developmental level of the child or the observed
injury. For example, bruising in non-ambulatory infants is always of
?Fractures are the second most common injury in physical abuse.
Certain types of fractures in children?such as metaphyseal corner
fractures, posterior rib fractures, and scapular fractures?are seen
almost exclusively in cases of abuse. However, the most common types
of fractures seen in abuse, such as linear skull fractures, are common
in cases of accidental injury as well. To recognize abuse in these
cases, the history reported by the caregiver is of critical
?RADIOLOGY: Injuries Associated with Abuse
Radiological examinations can be utilized to evaluate whether findings
have a significant association with abuse. The table below identifies
which injuries have a high specificity for abuse.
Diaphysial fractures are common accidental injuries. No type of
Diaphysial fracture is diagnostic of abuse.?
?Classic metaphyseal lesions
?Rib fractures, especially posterior
?Spinous process fractures
?Any infant with an unexplained fracture
Arm: ?In addition to the fractures displayed above, this patient also
has a small bucket handle fracture of the distal humeral metaphysis
and a small bucket handle fracture of the distal tibia. Both of these
are very hard to see (images not shown). These findings are
compatible with child abuse.?
Leg: ?Injuries at the epiphyseal-metaphyseal junction are highly
suggestive of abuse. The periosteum surrounding the growing long
bones is thick and tightly anchored at both ends by heavy extensions
into the epiphyseal cartilages. In contrast, the highly vascularized,
loosely attached young periosteum of the diaphysis is easily torn from
its underlying cortex.
The resultant subperiosteal bleeding lifts the periosteum, forming
layers of periosteal new bone away from the cortex to form an external
shell of new bone. This extremely strong periosteum that is tightly
anchored by heavy extensions into the epiphyseal cartilages can easily
explain the dynamics of epiphyseal-metaphyseal fractures.?
?Metaphyseal fractures were first described by Caffey
in 1972, who felt they represented an indirect avulsion injury to the
metaphysis by the pull of the periosteum when the child was severely
?In the case of questionable deaths, autopsy results can lead
medical examiners to conclude that injury was the cause. They can then
rule these injury deaths as homicides or suicides (intentional injury)
or accidents (unintentional injury).?
?An unintentional injury is not an accident. Both unintentional and
intentional injuries can be predicted and prevented.?
?Injuries seen in abuse are often distinctive because they are
inflicted by adults (and may therefore be significantly more violent
or purposeful than injuries sustained during normal childhood
activities). The history given to explain the injury may hold the key
to the abusive nature of the injury, especially if the injury and the
given history seem implausible. For example, a 4 year old presenting
with multiple cigaret burns is unlikely to have perpetrated this on
himself (too painful), or to have allowed another similiar-age child
to inflict the burns. Consideration of the history is always
inportant in any childhood injury. History must be correlated with the
developmental stage of the infant or child. A two month old baby
cannot, by himself, fall down stairs. This is not because he can't
fall (he can), but rather because part of falling is getting oneself
to the edge of the surface from which the fall occurred. A 2month old
isn't likely to crawl well enough (and for long enough) to get to the
top of the stairs entirely under his own power.
A baby could certainly unintentionally be dropped down the stairs,
but a well-intentioned caretaker who accidentally drops his child will
usually describe the accident as it happened ("I accidentally dropped
him while I was carrying him downstairs"), whereas an abusive
caretaker may give an evasive, inaccurate, and implausible history
such as "she was at the top of the stairs and rolled down." When we
consider this history, it becomes obvious how implausible it is (young
age of the infant). Similarly, consider this reason cited for a 4 year
old's skull fracture: an 18 month old sibling hit him with a baseball
bat. Swinging a bat (even being able to lift it) forcibly enough to
break a skull demonstrates considerable force and muscular
coordination - probably more than an 18 month old toddler can
?In infants under 12 months of age, fractures are highly suggestive
of abuse. Even infants who crawl or are able to walk do not
produce enough force in their own movements to cause a fracture.?
?Bucket-Handle or Corner Fractures - In any given bone, a mineralized
portion can appear on a radiograph to look like a bucket-handle. This
appears on the edge of the bone between the metaphysis and epiphysis.
This metaphyseal lesion is indicative of abuse. Radiologists
originally thought that ?corner? fractures occurred in the same area
of the bone as ?bucket-handle?, but these fractures have been found
to be one and the same depending on the angle at which an X-ray is
?When the child exhibits evidence of substantial or multiple skin
bruising or any other internal bleeding, any injury to skin causing
substantial bleeding, malnutrition, failure to thrive, burn or burns,
poisoning, fracture of any bone, subdural hematoma, soft tissue
swelling, extreme pain, extreme mental
distress, gross degradation, death -- when such condition or death may
not be the product of an accidental occurrence.?
?One of the major keys in determining the difference between
accidental injuries and abusive ones is that in abuse, the description
of the incidents does not match the injury. A history of a minor fall
in a child who presents with severe brain injury (brain swelling,
subdural hematoma, ruptured intracranial blood
vessels) is not compatible with a minor fall as the cause. The case at
the beginning of this chapter presented a classic example of this, in
which the history of a fall off the couch is alleged to have caused
the seizures, cerebral hemorrhages, retinal hemorrhages and fracture.
Children may experience different fracture patterns than adults
because of anatomical differences in the
structure of their bones. The immature bone has different amounts of
cartilage and the periosteum is thicker.
Children have a growth plate and the metaphyseal and epiphyseal
junction is prone to separation. Pediatric fractures are often
associated with plastic deformation such that when the bone is bent, a
permanent deformity occurs. The mechanism for fractures in children
and adults can be the same, which includes blunt trauma to a bone with
significant force to cause a fracture, twisting motions, and/or severe
shaking that can fracture bones (7).
Injuries that are suspicious for child abuse are spiral fractures in
non-ambulatory infants, which are due to twisting motions of the
humerus and/or femur. The metaphyseal fractures of long bones that are
often associated with severe shaking are particularly suggestive of
?A child is brought into the emergency room with a fractured leg. The
parents are unable to explain how the leg fractured. X-rays reveal
several other fractures in various stages of healing. The parents say
they did not know about these fractures, and cannot explain what might
have caused them. Hospital personnel call child welfare services to
report a suspected case of child abuse. The child is taken away from
the parents and placed in foster care.
Scenes like this occur in emergency rooms every day. But in this case,
the cause of the fractures is not child abuse. It is osteogenesis
imperfecta, or OI. OI is a genetic disorder characterized by bones
that break easily--often from little or no apparent cause. A person
with OI may sustain just a few or as many as several hundred fractures
in a lifetime.
What Is Osteogenesis Imperfecta?
Osteogenesis imperfecta is a genetic disorder of type 1 collagen--the
protein "scaffolding" of bone and other connective tissues. People
with OI have a faulty gene that instructs their bodies to make either
too little type 1 collagen or poor quality type 1 collagen. The result
is bones that break easily.?
?Look for clinical features of OI in the child--blue sclera;
translucent, opalescent, or discolored teeth (even in unerupted teeth
in babies); a triangular shaped face; barrel-shaped rib cage; easy
bruising; thin skin; excessive sweating; and other features. However,
it is possible for children with OI to exhibit none or few of the
outward clinical features.?
It's OK to Talk to Your Orthopaedic Surgeon About Family Violence
?The American Academy of Orthopaedic Surgeons is engaged in a program
to heighten the awareness of orthopaedic surgeons about the issues of
family violence, the ways to identify abuses and actions that can be
I hope this answer is what you were seeking. If not, or if anything is
unclear, please request an Answer Clarification, and allow me to
respond, before rating. I will be happy to assist you further on this
question, before you rate it.
Again, I do not mean to insinuate anyone is abusing an infant. But if
so, please see to it that this child receives prompt medical care,
regardless of the cause of injury.
determing abuse + bone fractures + infant
radiology + fractures + infants
infant + fractured ankle