Non-accidental injury and the Orthopaedic Surgeon.

Peter Worlock

Newcastle General Hospital

Role of doctors:

• Be aware of problem.• Recognise unusual injury patterns.• Initiate investigation.

Soft tissue injuries:

• Bites.• Burns.• Bruising.

Bites:

Bruising:

Soft tissue injuries – normal children:

• Head/face injuries rare <18 months.• Lumbar injuries unusual before age of 5 years.• Bruising of hands/feet and lower legs is most

common injury.

Roberton et al, 1982

Soft tissue injuries – NAI:

• Head/face injuries present in 60%.• Lumbar injuries common under age of 5 years.

Roberton et al, 1982

Fracture pattern:

• Accidental Injury (AI) – all children aged <13 years living in Nottingham Jan-June 1981 with a #.

• Study group – 826 consecutive children.

• Non-accidental injury (NAI) – all children aged <13 years in Nottingham with # from child abuse 1976-1982.

• Study group – 35 children.

Distribution by age (p<001):

NAI (n = 35) AI (n = 826)

< 18 months 28 (80%) 19 (2.3%)

19 – 60 months 7 (20%) 97 (11.8%)

61 – 155 months - 710 (85.9%)

Worlock et al, BMJ, 1986

Age - and sex-specific incidence rates – # caused by AI:

AI group # incidence during six month study period (p<0.001):

Pop. at risk Incidence

< 18 months 10,989 1.7/1000

19 – 60 months 23,564 4.8/1000

61 -155 months 68,288 10.4/1000

Worlock et al, BMJ, 1986

Annual # incidence (NAI : AI):

NAI AI

< 18 months 4/10,000 34/10,000

19 – 60 months 0.4/10,000 96/10,000

Worlock et al, BMJ, 1986

Number of fractures per child aged < 60 months (p<0.001):

NAI (n = 35) AI (n = 116)

1 # only 9 97

2 # only 7 19

> 2 # 19 -

Worlock et al, BMJ, 1986

Association with other injuries (p<0.001):

NAI (n = 35) AI (n = 116)

None 6 99

Burn 1 -

Minor HI 3 16

Trunk bruise 4 -

Limb bruise 3 -

Head bruise 18 1

Worlock et al, BMJ, 1986

Delay in presentation:

Patterns of # (aged < 18 months):

Patterns of # (aged 19 – 60 months):

Metaphyseal ‘chip’ #:

•Said to be “classic” pattern of # in NAI.

•Less common than often thought.

Rib #:

•Present in 54% of children in NAI group.

•None seen in AI group.

•All diagnosed on skeletal survey, after abuse suspected.

Spiral # of humeral shaft:

•Seen in 9 out of 35 children in NAI group.

•None seen in AI group (p<0.001)

Skull # after NAI:

•Multiple or complex #.•Involvement of more than one bone.•Non-parietal #.•Depressed #.•‘Growing’ #.

Femoral # in children aged < 4 years:

•80 femoral #.•Aetiology:

•Normal trauma/normal children 49%.•Child abuse 30%.•Pathological 12.5%.•Major trauma 8.5%.

Beals and Tuft, 1983

Risk of injury on falling out of bed:

• 76 children fallen from bed, cot or chair.• Height of falls from 1 – 3 ft.• Injuries:– Minor bruise/no injury 63.5%.– Head/face bruise or laceration 30.0%.– Linear skull # 1.3%.– Limb # (in pt with OI) 1.3%.

Nimityongskul & Anderson, 1987

NAI and osteogenesis imperfecta:

• Type I: autosomal dominant with blue sclera. Most common type.

• Type II: autosomal recessive with blue sclera. Lethal in foetal or perinatal period.

• Type III: autosomal recessive with normal sclera. Moderate/severe bone fragility with rapidly progressive deformity.

NAI and osteogenesis imperfecta:

• Type IV: autosomal dominant, but occasional spontaneous mutation. Normal sclera. Mild/moderate bone fragility with variable deformity.

• Rare! Incidence: 1 in 120,000 live births.

NAI and osteogenesis imperfecta:

• Occurrence in absence of blue sclera, no family history and lack of progressive deformity is about 1 in 3,000,000 live births.

• A city of 500,000 people with 6000 live births per year would produce one case of Type IV OI by spontaneous mutation every 100 – 300 years.

Taitz, BMJ, 1987

Other conditions causing spontaneous # in infancy :

• Prematurity. Usually <1500g at birth, with evidence of rickets and/or osteoporosis on XR. Raised Alk. Phosphatase.

• Copper deficiency. Can occur in pre-term babies given Cu-deficient feed, after TPN lacking Cu or in severe malabsorption with Cu-deficient diet. Children with # all have severe haematological abnormalities and osteoporosis on XR.

NAI and the Orthopaedic Surgeon:

• # uncommon in normal children < 18 months, but # due to NAI most common in this age group.

• 1 child in 8 aged < 18 months with a # may be victim of abuse.

• Rib # on skeletal survey, in absence of major chest trauma, is virtually diagnostic of NAI.

NAI and the Orthopaedic Surgeon:

• Metaphyseal ‘chip’ # relatively uncommon.• Diaphyseal injuries in NAI are due to

gripping/twisting – spiral # or periosteal new bone formation.

• You need to be able to recognise unusual injury patterns.

NAI and the Orthopaedic Surgeon:

• Be prepared to initiate investigation.• Know your own hospital’s procedure for

investigating suspected NAI.• Do not accuse parents – leave interviewing

family to the experts.• Children’s Act 1992 – safety and well-being of

the child is paramount.