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  • Epidemiology
    • incidence
      • >1 million children are victims of substantiated abuse or neglect in United States each year
      • child abuse is the second most common cause of death in children behind accidental injury 
      • head injury is the most frequent cause of long term physical morbidity in the child
    • demographics q
      • 90% of fractures due to abuse occur in children younger than 5 years of age
      • 50% of fractures in children younger than 1 year of age are attributable to abuse
      • 30% of fractures in children younger than 3 years of age are attributable to abuse 
      • the most common cause of femur fractures in the nonambulatory infant is nonaccidental trauma q
    • social risk factors q
      • child
        • first-born
        • unplanned pregnancy
        • premature
        • disabilities (cerebral palsy)
        • step-children
      • parent
        • single-parent home
        • recent social stressor (move, job loss)
        • unemployment
        • drug-use
        • personal history of abuse as a child
        • lower socioeconomic status
        • lack of support system
    • types (can have more than one type present):
      • neglect 78%
      • physical Abuse 18%
      • sexual 9%
      • psychological 8%
  • Prognosis
    • If unreported, 30-50% chance of repeat abuse and 5-10% chance of death from abuse
  • Differential diagnosis
    • true accidental injury
    • osteogenesis imperfecta
    • osteopenia of prematurity
    • scurvy 
    • copper deficiency
    • Menkes disease
    • disuse osteopenia (nonambulatory or minimally ambulatory children)
    • chronic disease (kidney and liver)
  • History
    • injury often inconsistent with history
    • red flags q q 
      • delay in seeking care
      • no history of injury or inconsistent story
      • long bone fractures in nonambulatory child q 
      • high specificity fractures
        • classic metaphyseal lesion 
          • fracture at junction of metaphysis and physis (primary spongiosa)
          • torsional / traction-shearing strain when infant's extremity is pulled or twisted violently
          • high specificity for child abuse
          • corner fractures  q  
            • discrete avulsion of the metaphysis
          • bucket handle fractures  
            • horizontal avulsion fracture with appearance of central and peripheral components gives the appearance of a bucket handle 
            • avulsed bone fragment may be seen en face  
          • rib fractures, especially posteromedial 
        • scapula fractures
        • sternal fractures
        • spinous process fractures
      • moderate specificity fractures
        • epiphyseal separations 
          • transphyseal separation of the distal humerus   
        • multiple fractures in various stages of healing 
        • vertebral body fractures and subluxations 
        • digital fractures
        • complex skull fractures
      • other injuries concerning for abuse - multiple bruises, burns
  • Symptoms
    • pain related to fractures
      • fractures are the second most common lesion in abused children  q q
        • frequency of fractures
          • humerus > tibia > femur q
          • diaphyseal fractures 4 times more common than metaphyseal
  • Physical exam
    • skin lesions 
      • most common presenting lesion q 
  • Radiographs
    • recommended views
      • AP and lateral of bone or joint of suspicion 
      • initial evaluation should include skeletal survey q 
  • Bone scan
    • alternative or adjunct to the radiographic skeletal survey in selected cases, particularly for children older than 1 year of age
    • provides increased sensitivity for detecting rib fractures, subtle shaft fractures, and areas of early periosteal elevation
    • not useful in metaphyseal or cranial fractures
  • Nonoperative
    • report abuse to appropriate agency 
      • indications
        • physicians are mandated reporters and are legally obligated to report suspected child abuse and neglect
        • physicians are granted immunity from civil and criminal liability if they report in good faith, but may be charged with a crime for failure to report
        • early involvement of social workers and pediatricians is essential
    • hospital admission
      • indications
        • early multidisciplinary evaluation  
        • admit infants with fractures to the hospital and consult child protective services 
        • obtain social service consult
    • cast application
      • indications
        • most fractures are splinted or casted until adequate callus is formed
  • Operative
    • rarely neccessary
    • definitive treatment as indicated for particular injury

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