Introduction

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  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  social risk factors  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)

Presentation

History injury often inconsistent with history red flags    delay in seeking care no history of injury or inconsistent story long bone fractures in nonambulatory child   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     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   frequency of fractures humerus > tibia > femur  diaphyseal fractures 4 times more common than metaphyseal Physical exam skin lesions  most common presenting lesion

Imaging

Radiographs recommended views AP and lateral of bone or joint of suspicion  initial evaluation should include skeletal survey   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

Treatment

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