Skeletal Aspects of Non-Accidental Injury.

Chapter 15 Allgrove J, Shaw NJ (eds): Calcium and Bone Disorders in Children and Adolescents. 2nd, revised edition. Endocr Dev. Basel, Karger, 2015, vol 28, pp 247–258 (DOI: 10.1159/000381049)

Skeletal Aspects of Non-Accidental Injury Karl Johnson · Karen Bradshaw Birmingham Children’s Hospital, Birmingham, UK

Introduction

Inflicted non-accidental skeletal injuries form a small but important part of the spectrum of child abuse, with the majority of skeletal injuries occurring in children under 2 years of age. Radiology plays a vital role in the detection and evaluation of these skeletal injuries. A thorough detailed radiological evaluation should be undertaken to investigate a child appropriately for a suspected inflicted non-accidental injury to accurately detect and possibly date any injuries and also to exclude normal variants of growth that may mimic fractures. In some cases, the survey may diagnose an underlying metabolic or genetic disorder of the bone that may predispose the child to fracturing. While radiology plays an important role in the dating of injuries, the dating of fractures from radiological appearances is difficult and imprecise. Any fracture may be the result of an inflicted injury or accidental event. Therefore, it is important that all fractures identified are correlated with any relevant clinical history. Certain injuries, such as rib and metaphyseal fractures, require a more specific method of causation and therefore carry a higher degree of suspicion of being the result of an inflicted injury compared with other fracture types, which are relatively non-specific in their mechanisms of causation, such as skull and clavicular fractures. In all cases, correlation with clinical history is mandatory. © 2015 S. Karger AG, Basel

One of the most challenging areas of paediatric medicine is that relating to child abuse. Child abuse covers a wide spectrum of injuries and assaults that includes social, sexual and emotional as well as physical events. Consequently, the diagnosis of a child as having suffered from an episode of abuse has significant social, criminal and civil implications [1]. Non-accidental injury is the term often used when a child has suffered an episode of physical abuse. The physical abuse of children is unfortunately not uncommon, and reports have indicated that between 4 and 16% of children are abused each year [2]. Child maltreatment and abuse significantly contribute to child mortality and morbidity [2]. Up to 30% of abused children returned to the care of their abuser suffer from further injury [3]. The investigation of children who have suffered potential abuse should be multi-disciplinary and involve paediatricians, physicians with relevant medical subspecialties and other healthcare and social professionals. Radiology provides a relatively small but important contribution to the investigation of skeletal and visceral injuries. Visceral injuries are common in the older children, whilst skeletal and cerebral trauma are typDownloaded by: UCONN Storrs 198.143.38.1 - 6/17/2015 10:28:34 PM

Abstract

Radiological Investigation of Suspected Abuse

A radiological skeletal survey is the standard initial imaging modality for assessing young children who are suspected of having been physically abused [6]. Typically, it should be performed for all children under 2 years of age in whom there is clinical suspicion of abuse. For older children, a detailed discussion between the referring paediatrician and the radiologist about the potential yield of such an investigation and its value, measured against the radiation dose, should be discussed. The yield of imaging is higher in 1-year-old children [6]. The radiation dose of a skeletal survey is not inconsequential and therefore, the discussion about the need for a skeletal survey should occur at the senior clinical level. The indications for a

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skeletal survey are variable and beyond the scope of this chapter, but important risk factors include bruising and burns because 14% of children identified with these injuries have occult fractures. Children presenting with an apparent life-threatening event, apnoea or seizures have the highest rate of positive skeletal surveys compared with those presenting for other reasons. Abusive head trauma is also significantly associated with a positive skeletal survey. The purpose of the skeletal survey is to detect any occult bony injury, obtain further information about any clinically suspected fracture, aid in the dating of injuries and help to provide any evidence of a possible underlying skeletal disorder or metabolic bone disease that may predispose the child to fracturing. Radiographic imaging should be of a high standard with good-quality collimation and optimised exposure parameters [7, 8]. A variety of guidelines published by national radiological societies exists to help in the achievement of the appropriate level of quality. Ideally, all radiology staff involved in carrying out the study should be appropriately paediatrically trained [6]. A skeletal survey consists of radiographs of each anatomical site, and the standard projections required are shown in table 1. Although fractures limited to sites other than the long bones, ribs, skull, and clavicles are rare, the additional radiation exposure and cost of obtaining radiographs of the spine, pelvis, hands, and feet may outweigh their potential benefits, and consideration may be given to eliminating these views from routine skeletal surveys performed to evaluate a child for suspected abuse [9]. Supplementary views should include a lateral view of any fractures and coned-down views of the metaphyses when the features are suggestive of a fracture or otherwise equivocal findings are obtained [10, 11]. Repeat radiographs of areas of uncertainty should be performed within 1–2 weeks [12, 13]. This delay will allow time for a radiographically detectable healing response to occur around po-

Johnson · Bradshaw Allgrove J, Shaw NJ (eds): Calcium and Bone Disorders in Children and Adolescents. 2nd, revised edition. Endocr Dev. Basel, Karger, 2015, vol 28, pp 247–258 (DOI: 10.1159/000381049)

Downloaded by: UCONN Storrs 198.143.38.1 - 6/17/2015 10:28:34 PM

ically observed in non-ambulant children. Each may co-exist or occur separately. Skeletal injuries commonly occur in non-ambulant children who are under 2 years of age but are more common in those under 1 year of age [4]. This chapter will deal with the radiological features of skeletal injuries associated with nonaccidental injury and consequently, will almost exclusively refer to children under 2 years of age. The site and type of fracture or skeletal injury alone can never be completely discriminatory of abuse or accident [5]. The age and development of children are vitally important because an unexplained injury, such as a fractured femur, in a non-ambulatory 2-month-old infant should be treated completely differently from the same fracture in a 15-year-old adolescent [1]. For each injury, it is vitally important that a clear history of how the injury occurred is obtained. This history has to be carefully correlated with the clinical symptoms and radiological findings. From the radiological features alone, no fracture should be regarded as being pathognomonic of abuse [4].

Table 1. The Projections Required for a Radiographic Skeletal Survey for the Investigation of NAI Skull: anterior posterior (AP) and lateral; additional Townes view (if clinically indicated). Skull films should be obtained even if a CT scan has been performed. Chest: AP to include the clavicles and oblique views of both sets of ribs Abdomen, including the pelvis and hips Spine: lateral view of the cervical, thoracic and lumbar regions (if the whole spine is not seen on the chest and abdominal films, then additional views may be required) Limbs – AP views of both humeri, both forearms, both femora and both tibiae and fibulae – Hands: posterior anterior (PA) – Feet: dorsipalmar (DP) NAI = Non-accidental injury.

additional information regarding physeal and epiphyseal injuries and may identify changes even when radiographs are negative. Whole-body MRI has a high specificity but low sensitivity for detecting fractures [19]. High-resolution ultrasound has been used for the identification of periosteal elevation and metaphyseal and rib injuries [4, 20–24]. Ultrasound, CT and MRI are useful and complementary problem-solving tools, but it is important that the initial radiological investigation is a high-quality skeletal survey.

Skeletal Features

No fracture can be regarded as diagnostic of nonaccidental injury. Any fracture can be caused by an accident or can occur from an inflicted nonaccidental injury [1, 4, 25]. Thus, for all fractures, it is important that there is an appropriate history of a mechanism of causation and clinical presentation. From a clinical view, it is important that the history includes the child’s development, including his or her ability to crawl or walk. With regard to the clinical presentation, different fracture types will manifest with different symptoms, and this should also be considered. A non-accidental injury should be considered if no history to account for the injury is provided or if the ac-

Radiology of NAI Allgrove J, Shaw NJ (eds): Calcium and Bone Disorders in Children and Adolescents. 2nd, revised edition. Endocr Dev. Basel, Karger, 2015, vol 28, pp 247–258 (DOI: 10.1159/000381049)

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tential injuries, helping to confirm or refute equivocal findings and also improving the detection of occult injuries. A repeat chest radiograph with oblique views of the ribs should be obtained routinely because the detection of rib fractures is increased by over 20% [14, 15]. There is evidence indicating that repeat views of the limbs and extremities will increase the yield of occult injuries. Scintigraphy (nuclear medicine bone scan) is a complementary investigation to the skeletal survey. Used together, these two investigations detect more fractures than each investigation singularly. Bone scintigraphy has a better detection rate for rib fractures. However, it is less sensitive in detecting skull, spine and metaphyseal fractures [16, 17], the latter as a consequence of the normal high activity seen in the physis of the developing skeleton. As with the skeletal survey, it is important that the bone scan is performed with high technical quality, and in view of the relatively high radiation dose of the bone scan, the investigation should not be undertaken unless the quality of the images is satisfactory [6]. Computerised tomography (CT) may have a role in helping to determine the nature of equivocal radiographic findings. It appears to be more sensitive than radiographs in detecting occult rib fractures [18]. Magnetic resonance imaging (MRI) and ultrasound are both useful for the evaluation of soft tissue lesions. MRI may add

Table 2. Specificity of fractures in NAI

Rib Fractures

Reduced Skull Clavicle Long bone Periosteal reaction Epiphyseal separation Increased Multiple fractures of different ages Metaphyseal Ribs (posterior) Acromion Digits Sternum Spine

Rib fractures are uncommon in children under 3 years of age and are the result of severe thoracic compression. Posterior fractures are thought to occur due to the levering of the end of the rib over the transverse position of the vertebral body [30– 32]. An infant’s ribs are relatively elastic and allow a considerable degree of deformation prior to fracturing. Consequently, the force needed to produce rib fractures is significant, and in the absence of a major trauma or underlying bone abnormality, the presence of rib fractures in a child indicates possible non-accidental injury. In children under 18 months of age with rib fractures, the odds ratio for abuse is 23.7, and it is 9.1 in those over 18 months of age [4]. Rib fractures following cardio-pulmonary resuscitation are rare, and many studies have failed to detect fractures in large numbers of children who have undergone this procedure [33–36]. Conditions that predispose children to bone fragility, such as osteopaenia of prematurity or bone dysplasia, are relatively common causes of rib fractures in the infant/toddler population [37–39]. Rib fractures following abuse can occur at any location and may be unilateral or bilateral. Rib fractures are not often associated with chest wall bruising. However, fingertip bruising may be a related clinical feature. In some cases, an acute rib fracture may not be easily detected on the initial radiograph because the position of the fracture is in the line of the Xray beam. However, repeat radiographs performed 1–2 weeks later will show evidence of callus formation around fracture sites, increasing the detection of fractures (fig. 1) [30].

count given differs when retold. A review of the different fracture types and their relative specificities in non-accidental injury is given in table 2. The list reflects the incidence of different fracture types in abused children. It also takes into account the fact that certain fracture types, such as rib fractures, require a more precise method of causation compared with other injuries, such as skull fractures. This classification system only provides a guideline, and each fracture and its clinical presentation should be fully assessed without prejudice.

Fracture Distribution

Fractures that are the result of abuse predominantly occur in the infant-toddler age groups. Studies have shown that 80% of all fractures resulting from abuse are seen in children under 18 months of age, and by contrast, 85% of fractures not due to abuse occur in children over 5 years of age [4, 26]. Approximately 25–50% of fractures occurring in children under 1 year of age are due to abuse, and there is an association between multiple fractures and abuse [27–29].

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Metaphyseal Fractures

Metaphyseal fractures are the result of microfractures across the metaphysis adjacent to the physis, with the fracture plane being parallel to



NAI = Non-accidental injury.

b

Fig. 1. a Oblique view of the left ribs show acute left sided rib fractures (arrowed). b Follow-up AP radiograph of the chest taken three weeks later shows the healing response around the previously identified fractures, but there is now identifiable callus formation around the anterior ends of the left ribs (arrows), indicating fractures which were present but not visible on the initial film. These fractures were more difficult to visualise on the initial chest radiograph and their detection has been aided by the healing response around them. Note that these fractures are in a line and show the same degree of callus formation, suggesting that they were all sustained during a single event.

the physis. This type of injury is believed to be the result of severe shearing force, which is not typically replicated when a child falls or suffers from blunt trauma [40]. Therefore, relatively specific mechanisms cause metaphyseal fractures, such as the application of pulling/torsional forces to the limb or the allowing of an unsupported limb to flail about violently. On radiographs, classical metaphyseal fractures often appear as small, thin slivers of bone separated from the shaft, and depending on how the bone is projected, it may create a ‘bucket handle’ appearance or resemble a chip or corner-type injury (fig. 2, 3). The fractured bone fragment may be thicker at the periphery, or it may appear as a thin disc or rim. Depending on the extent of the injury, there may not be any disruption or elevation of the adjacent periosteum and, as a consequence, the amount of subperiosteal haemorrhaging and subsequent new bone and callus formation may be limited (fig. 4) [40, 41]. Metaphyseal fracture can occasionally be confused with the normal beaking and irregularities seen around the metaphysis of the immature skeleton. Many of these normal variations in growth have been described and documented [42, 43]. In addition, metaphyseal fractures may be missed if appropriate radiography is not employed. If clinical doubt exists, then either additional radio-


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a

Fig. 2. Metaphyseal fracture of the proximal left tibia shows a separated slither of bone from the proximal metaphysis which has a classic ‘bucket handle’ appearance.

smooth and is no more than 1.8 mm in thickness on AP radiograph. In addition, it is not layered and does not extend beyond the metaphysis. Typically, it would not be expected to change over a 2 week period (fig. 6) [44]. Pathological, post-traumatic subperiosteal new bone obviously forms in older children, and not all periosteal new bone formation in younger children is normal. On radiographs, it often appears thicker, is layered, can have a convex border, is greater than 2 mm in depth and can extend down into the distal metaphysis and periphysis regions. Serial radiographs over a 2 week period would be expected to show changes (fig. 7).

graphs to view the findings in another imaging plane or repeat radiographs to document possible bone healing can be helpful.

Subperiosteal New Bone Formation

Subperiosteal new bone is seen as a hazy and indistinct margin separated from the cortex. It may become visible as part of a healing response to a fracture or as a result of subperiosteal haemorrhage caused by a gripping/twisting force applied to a limb that disrupts the periosteal attachment to the bone (fig. 5). It also occurs as a normal physiological response in growing children in response to fracture healing due to elevation of the periosteum and subperiosteal haemorrhage. It can be seen in other pathological processes, such as the response to infection or malignant infiltration of bone. Periosteal new bone formation due to growth typically occurs in children who are less than 4 months of age. It can occur in multiple locations and has an asymmetrical distribution. The tibia is the most common site at which it occurs, but it can occur in any of the long bones. It is typically

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Long Bone Fractures

Obtaining an appropriate history of a possible method of causation is very important in determining if a long bone fracture is the result of an inflicted injury. The likelihood of an unexplained fracture being the result of abuse increases in non-ambulant children compared with those who are independently mobile. Multiple fractures are more common after physical abuse than after a non-abusive traumatic injury [4]. The morphology and appearance of a long bone fracture may suggest a possible mechanism of injury, which is of potential value when assessing the validity of any explanation given by the carers. For example, a spiral fracture will require a twisting or torsional component to the force, while an oblique fracture is typically the result of a levering or bending type action, a transverse fracture is often due to a direct impact, and a buckle or torus fracture is commonly the result of a compression injury. There have been a number of reports reviewing the incidence of long bone fractures in abused and non-abused children [4, 26, 29, 45–51]. While these statistics are important in assessing the likelihood of these injuries being the result of abuse, it must be remembered that each individ-



Fig. 3. Metaphyseal fracture of the proximal left tibia showing a ‘bucket handle’ fracture.

a

b

Fig. 4. a Lateral radiograph shows a metaphyseal corner fracture of the distal left tibia. b Follow up radiograph of the right ankle shows extensive periosteal new bone along the distal tibia and sclerosis along the metaphysis. Appearances are consistent with a healing metaphyseal fracture.

Midshaft fractures of the humerus are more common in cases of abuse, while supracondylar fractures are more likely to be associated with a nonabuse injury [4].

Skull Fractures

Skull fractures are more commonly seen after accidental trauma than following abuse. The most common fracture site in both abused and accidental events is the parietal bone, and the most common fracture type is a linear pattern [4]. The significance of more complex fracture patterns has not been substantiated. An infant or toddler with a skull fracture has a 1 in 3 chance of having being abused [4].


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ual fracture in each case should be assessed separately. Femoral fractures resulting from abuse are more commonly seen in children who are not yet walking, and a child with a femoral fracture has a 1 in 3–4 chance of having been abused [4]. However, the most common cause of femoral fractures in children less than 4 years of age is a fall of less than one metre. Spiral/oblique fractures of the femur are the most common type of injury in abused children under 15 months of age. The most common location of fractures in both abused and non-abused children is the midshaft. In children under 18 months of age, 96% of all fibula/tibial fractures result from abuse [4]. A child under the age of three with a humeral fracture has a 1 in 2 chance of having been abused.

Fig. 5. AP radiograph of the left humerus. There is periosteal new bone formation around the metadiaphysis extending into the metaphysis. There is sclerosis on the lateral aspect of the distal humeral metaphysis. There is some cortical irregularity of the metaphysis. The appearances indicate a healing metaphyseal fracture of the distal humerus with pathological new bone formation.

Fig. 6. Normal physiological subperiosteal new bone formation along the tibia. This is a single lamina which does not extend as far as the metaphysis.

Skull fracture can occur from falls, and it has been estimated that falls from about three feet in height result in a skull fracture in about 1–2% of cases. Falls from below three feet may still cause a skull fracture, depending on the type of impact [52].

ticularly if there is no immediate explanation, should prompt the clinician to identify the potential method of causation. Unusual injuries include fractures of the spine, scapula, sternum, pelvis, fingers and toes in non-ambulatory children (fig. 8, 9).

Birth-Related Fractures Unusual Fractures

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Fractures can occur at birth, and the incidence appears to be increased in macrosomic infants. Rib fractures have been described in association with shoulder dystocia, and metaphyseal fractures have



Fractures at uncommon sites are usually the result of unusual mechanisms and injuries. Injuries that do not occur from routine paediatric trauma, par-

Fig. 8. Healing fracture of the metacarpal of the thumb in a child which is most likely the result of a severe squeezing injury.

been reported following caesarian section delivery. Femoral fractures are a rare birth injury. Studies have suggested that fractures, including metaphyseal injuries, are often painful and may be associated with tenderness and swelling [53–56].

Fracture Dating

The dating of fractures is based on the subjective evaluation of radiographic changes in healing that occur around fracture sites. These changes include the presence and subsequent resolution

Fig. 9. Healing fracture of the right acromion.

of any soft tissue swelling, the appearance of early subperiosteal new bone followed by formation of bridging callus across the fracture site and the loss of fracture line differentiation. More organised callus formation and the appearance of lamellar bone are features that appear later [57–59]. Both long bone and rib fractures follow predictable patterns of healing that can guide radiologists in estimating the age of the fracture [60, 61]. The radiological features of bone healing form a continuum, with considerable overlap. The dating of fractures is obviously open to subjective opinion as to the stage of fracture healing, and it


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Fig. 7. Pathological periosteal new bone formation along the shaft of the distal humerus which is thickened and extends into the metaphysis. Follow-up film showed remodelling and reabsorption.

a

also must be recognised that there is a wide variation in the rate of healing, both between individuals and even between separate injuries in the same individual. Early radiographic features of callus can be first noted within 5 days after injury, while the absence of subperiosteal new bone suggests that a fracture is likely to be less than eleven days old. Subperiosteal new bone formation has been found to be the only feature that can be reliably assessed in infants [62]. More mature callus and early remodelling are seen at 8 weeks in most cases but may occur earlier. Radiological dating can only indicate a relatively wide time frame and is at best an approximation [57–59], and estimates of the time of injury are made in terms of weeks rather than days. However, radiologists can clearly differentiate recent from old fractures (fig. 10) [58]. Importantly, any fracture must be correlated with the clinical history and the onset of appropriate clinical symptoms and signs. There is an assumption that when a fracture occurs, it will be

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b

painful, and the nature and duration of this pain will vary between individuals and also possibly among different fracture types. Importantly, if a child presents with a history of being asymptomatic and subsequently showing signs of distress and loss of limb functioning, then this would be a more accurate method of dating an injury than a radiological survey. The majority of childhood fractures are not associated with bruising [63].

Summary

It is important to be able to identify non-accidental injuries, but it is equally important to distinguish them from accidental trauma. Radiology is only one tool that can be used in this process, and it is not an exact science. It is an important adjunct that must be used in conjunction with all of the other methods and processes that are available, particularly the acquisition of good and detailed personal and family histories.



Fig. 10. a Transverse fracture of the right femur with extensive soft tissue swelling. b Follow-up films ten days later show very early subperiosteal new bone formation around the fracture site.

References 11 Jha P, Stein-Wexler R, Coulter K, Seibert A, Li CS, Wootton-Gorges SL: Optimizing bone surveys performed for suspected non-accidental trauma with attention to maximizing diagnostic yield while minimizing radiation exposure: utility of pelvic and lateral radiographs. Pediatr Radiol 2013;43:668–672. 12 Karmazyn B, Duhn RD, Jennings SG, Wanner MR, Tahir B, Hibbard R, Hicks R: Long bone fracture detection in suspected child abuse: contribution of lateral views. Pediatr Radiol 2012;42:463– 469. 13 Singh R, Squires J, Fromkin JB, Berger RP: Assessing the use of follow-up skeletal surveys in children with suspected physical abuse. J Trauma Acute Care Surg 2012;73:972–976. 14 Sonik A, Stein-Wexler R, Rogers KK, Coulter KP, Wootton-Gorges SL: Follow-up skeletal surveys for suspected non-accidental trauma: can a more limited survey be performed without compromising diagnostic information? Child Abuse Negl 2010;34:804–806. 15 Zimmerman S, Makoroff K, Care M, Thomas A, Shapiro R: Utility of followup skeletal surveys in suspected child physical abuse evaluations. Child Abuse Negl 2005;29:1075–1083. 16 Haase GM, Ortiz VN, Sfakianakis GN, Morse TS: The value of radionuclide bone scanning in the early recognition of deliberate child abuse. J Trauma 1980;20:873–875. 17 Mandelstam SA, Cook D, Fitzgerald M, Ditchfield MR: Complementary use of radiological skeletal survey and bone scintigraphy in detection of bony injuries in suspected child abuse. Arch Dis Child 2003;88:387–390; discussion 387– 390. 18 Wootton-Gorges SL, Stein-Wexler R, Walton JW, Rosas AJ, Coulter KP, Rogers KK: Comparison of computed tomography and chest radiography in the detection of rib fractures in abused infants. Child Abuse Negl 2008;32:659– 663. 19 Eltermann T, Beer M, Girschick HJ: Magnetic resonance imaging in child abuse. J Child Neurol 2007;22:170–175. 20 Kelloff J, Hulett R, Spivey M: Acute rib fracture diagnosis in an infant by US: a matter of child protection. Pediatr Radiol 2009;39:70–72.

21 Markowitz RI, Hubbard AM, Harty MP, Bellah RD, Kessler A, Meyer JS: Sonography of the knee in normal and abused infants. Pediatr Radiol 1993;23:264–267. 22 Nimkin K, Kleinman PK, Teeger S, Spevak MR: Distal humeral physeal injuries in child abuse: MR imaging and ultrasonography findings. Pediatr Radiol 1995; 25:562–565. 23 Warkentine FH, Horowitz R, Pierce MC: The use of ultrasound to detect occult or unsuspected fractures in child abuse. Pediatr Emerg Care 2014;30:43–46. 24 Griffith JF, Rainer TH, Ching AS, Law KL, Cocks RA, Metreweli C: Sonography compared with radiography in revealing acute rib fracture. AJR Am J Roentgenol 1999;173:1603–1609. 25 Taitz J, Moran K, O’Meara M: Long bone fractures in children under 3 years of age: is abuse being missed in emergency department presentations? J Paediatr Child Health 2004;40:170–174. 26 Carty H, Pierce A: Non-accidental injury: a retrospective analysis of a large cohort. Eur Radiol 2002;12:2919–2925. 27 Chang W, Barnes AM, Cabral WA, Bodurtha JN, Marini JC: Prolyl 3-hydroxylase 1 and CRTAP are mutually stabilizing in the endoplasmic reticulum collagen prolyl 3-hydroxylation complex. Hum Mol Genet 2010;19:223–234. 28 Warrington SA, Wright CM: Accidents and resulting injuries in premobile infants: data from the ALSPAC study. Arch Dis Child 2001;85:104–107. 29 Worlock P, Stower M, Barbor P: Patterns of fractures in accidental and nonaccidental injury in children: a comparative study. Br Med J (Clin Res Ed) 1986; 293:100–102. 30 Kleinman PK, Marks SC, Adams VI, Blackbourne BD: Factors affecting visualization of posterior rib fractures in abused infants. AJR Am J Roentgenol 1988;150:635–638. 31 Kleinman PK, Marks SC Jr, Nimkin K, Rayder SM, Kessler SC: Rib fractures in 31 abused infants: postmortem radiologic-histopathologic study. Radiology 1996;200:807–810. 32 Kleinman PK, Marks SC Jr, Richmond JM, Blackbourne BD: Inflicted skeletal injury: a postmortem radiologic-histopathologic study in 31 infants. AJR Am J Roentgenol 1995;165:647–650.


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1 Sugar NF: Diagnosing child abuse. BMJ 2008;337:a1398. 2 Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S: Burden and consequences of child maltreatment in high-income countries. Lancet 2009; 373:68–81. 3 Ellaway BA, Payne EH, Rolfe K, Dunstan FD, Kemp AM, Butler I, Sibert JR: Are abused babies protected from further abuse? Arch Dis Child 2004;89:845–846. 4 Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, Datta S, Thomas DP, Sibert JR, Maguire S: Patterns of skeletal fractures in child abuse: systematic review. BMJ 2008;337:a1518. 5 Pandya NK, Baldwin K, Wolfgruber H, Christian CW, Drummond DS, Hosalkar HS: Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center. J Pediatr Orthop 2009; 29:618–625. 6 Royal College of Radiologists, Royal College of Paediatrics and Child Health: Standards for Radiological Investigations of Suspected Non-accidental Injury. Intercollegiate Report. London, Royal College of Radiologists and Royal College of Paediatrics and Child Health, 2008. 7 Duffy SO, Squires J, Fromkin JB, Berger RP: Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys. Pediatrics 2011;127:e47–e52. 8 Kleinman PK, Nimkin K, Spevak MR, Rayder SM, Madansky DL, Shelton YA, Patterson MM: Follow-up skeletal surveys in suspected child abuse. AJR Am J Roentgenol 1996;167:893–896. 9 Barber I, Perez-Rossello JM, Wilson CR, Kleinman PK: The yield of high-detail radiographic skeletal surveys in suspected infant abuse. Pediatr Radiol 2015;45: 69–80. 10 Karmazyn B, Lewis ME, Jennings SG, Hibbard RA, Hicks RA: The prevalence of uncommon fractures on skeletal surveys performed to evaluate for suspected abuse in 930 children: should practice guidelines change? AJR Am J Roentgenol 2011;197:W159–W163.

33 Betz P, Liebhardt E: Rib fractures in children – resuscitation or child abuse? Int J Legal Med 1994;106:215–218. 34 Bush CM, Jones JS, Cohle SD, Johnson H: Pediatric injuries from cardiopulmonary resuscitation. Ann Emerg Med 1996;28:40–44. 35 Feldman KW, Brewer DK: Child abuse, cardiopulmonary resuscitation, and rib fractures. Pediatrics 1984;73:339–342. 36 Spevak MR, Kleinman PK, Belanger PL, Primack C, Richmond JM: Cardiopulmonary resuscitation and rib fractures in infants. A postmortem radiologicpathologic study. JAMA 1994;272:617– 618. 37 Barsness KA, Cha ES, Bensard DD, Calkins CM, Partrick DA, Karrer FM, Strain JD: The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma 2003;54:1107–1110. 38 Schweich P, Fleisher G: Rib fractures in children. Pediatr Emerg Care 1985;1: 187–189. 39 Thomas PS: Rib fractures in infancy. Ann Radiol (Paris) 1977;20:115–122. 40 Kleinman PK, Marks SC, Blackbourne B: The metaphyseal lesion in abused infants: a radiologic-histopathologic study. AJR Am J Roentgenol 1986;146: 895–905. 41 Kleinman PK, Marks SC Jr: A regional approach to the classic metaphyseal lesion in abused infants: the proximal tibia. AJR Am J Roentgenol 1996;166: 421–426. 42 Kleinman PK, Belanger PL, Karellas A, Spevak MR: Normal metaphyseal radiologic variants not to be confused with findings of infant abuse. AJR Am J Roentgenol 1991;156:781–783. 43 Kleinman PK, Kwon DS: Differential diagnosis IV: normal variants; in: Kleinman PK (ed): Diagnostic Imaging of Child Abuse. St Louis, Mosby, 1998.

44 Kwon DS, Spevak MR, Fletcher K, Kleinman PK: Physiologic subperiosteal new bone formation: prevalence, distribution, and thickness in neonates and infants. AJR Am J Roentgenol 2002;179: 985–988. 45 Beals RK, Tufts E: Fractured femur in infancy: the role of child abuse. J Pediatr Orthop 1983;3:583–586. 46 Coffey C, Haley K, Hayes J, Groner JI: The risk of child abuse in infants and toddlers with lower extremity injuries. J Pediatr Surg 2005;40:120–123. 47 Leventhal JM, Thomas SA, Rosenfield NS, Markowitz RI: Fractures in young children. Distinguishing child abuse from unintentional injuries. Am J Dis Child 1993;147:87–92. 48 Merten DF, Radkowski MA, Leonidas JC: The abused child: a radiological reappraisal. Radiology 1983;146:377–381. 49 Shaw BA, Murphy KM, Shaw A, Oppenheim WL, Myracle MR: Humerus shaft fractures in young children: accident or abuse? J Pediatr Orthop 1997;17:293– 297. 50 Strait RT, Siegel RM, Shapiro RA: Humeral fractures without obvious etiologies in children less than 3 years of age: when is it abuse? Pediatrics 1995;96: 667–671. 51 Thomas SA, Rosenfield NS, Leventhal JM, Markowitz RI: Long-bone fractures in young children: distinguishing accidental injuries from child abuse. Pediatrics 1991;88:471–476. 52 Johnson K, Fischer T, Chapman S, Wilson B: Accidental head injuries in children under 5 years of age. Clin Radiol 2005;60:464–468. 53 Barry PW, Hocking MD: Infant rib fracture – birth trauma or non-accidental injury. Arch Dis Child 1993;68:250.

54 Morris S, Cassidy N, Stephens M, McCormack D, McManus F: Birth-associated femoral fractures: incidence and outcome. J Pediatr Orthop 2002;22:27–30. 55 O’Connell A, Donoghue VB: Can classic metaphyseal lesions follow uncomplicated caesarean section? Pediatr Radiol 2007;37:488–491. 56 van Rijn RR, Bilo RA, Robben SG: Birthrelated mid-posterior rib fractures in neonates: a report of three cases (and a possible fourth case) and a review of the literature. Pediatr Radiol 2009;39:30–34. 57 Islam O, Soboleski D, Symons S, Davidson LK, Ashworth MA, Babyn P: Development and duration of radiographic signs of bone healing in children. AJR Am J Roentgenol 2000;175:75–78. 58 Prosser I, Maguire S, Harrison SK, Mann M, Sibert JR, Kemp AM: How old is this fracture? Radiologic dating of fractures in children: a systematic review. AJR Am J Roentgenol 2005;184: 1282–1286. 59 Yeo LI, Reed MH: Staging of healing of femoral fractures in children. Can Assoc Radiol J 1994;45:16–19. 60 Prosser I, Lawson Z, Evans A, Harrison S, Morris S, Maguire S, Kemp AM: A timetable for the radiologic features of fracture healing in young children. AJR Am J Roentgenol 2012;198:1014–1020. 61 Sanchez TR, Nguyen H, Palacios W, Doherty M, Coulter K: Retrospective evaluation and dating of non-accidental rib fractures in infants. Clin Radiol 2013;68:e467–e471. 62 Halliday KE, Broderick NJ, Somers JM, Hawkes R: Dating fractures in infants. Clin Radiol 2011;66:1049–1054. 63 Mathew MO, Ramamohan N, Bennet GC: Importance of bruising associated with paediatric fractures: prospective observational study. BMJ 1998;317: 1117–1118.

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Karen Bradshaw Birmingham Children’s Hospital Steelhouse Lane Birmingham B4 6NH (UK) E-Mail [email protected]

Infant head injury in falls and nonaccidental trauma: does injury pattern correlate with mechanism?

Nonaccidental poisoning in childhood.

Subdural to subgaleal shunts: alternative treatment in infants with nonaccidental traumatic brain injury?

Nonaccidental trauma and failure to thrive.

Aspects of injury patterns in automobile accidents.

Legal aspects of child injury or neglect.

Radiological aspects of non-accidental injury.

Aspects of coma after severe head injury.

Comparative aspects of cardiac and skeletal muscle sarcoplasmic reticulum.

Morphometric aspects of the facial and skeletal muscles in fetuses.

Vegetation Delight? Greenness and Reduced Risk of Nonaccidental Death.

Treatment of skeletal muscle injury: a review.

Serum Cardiac Troponin I in the Evaluation of Nonaccidental Trauma.

[Moped accidents: injury mechanisms and clinicopathological aspects].

Characteristics of spinal injuries secondary to nonaccidental trauma.

Tissue engineered strategies for skeletal muscle injury.

Some medicolegal aspects of the management of acute head injury.

Biomechanical aspects of a fluid percussion model of brain injury.

[Spinal cord injury (SCI) - Aspects of intensive medical care].

Psychological aspects of severe physical injury and its treatment.

Angiographic aspects of experimental nonocclusive intestinal ischemic injury.

Environmental aspects of injury and disease: liver and bile ducts.

Neurobehavioral aspects of postconcussive symptoms after mild head injury.

Quantitative aspects in the assessment of liver injury.