Child abuse is far more common than bone disorders. Nevertheless, the clinician must consider the possibility of pre-existing medical conditions associated with bone fragility, and radiographic abnormalities must be interpreted carefully to avoid misinterpretation Figure 2 . The history should include all recent and remote traumatic events and any known medical conditions.
Document prior and current medication use, including vitamin supplements, notably vitamin D.
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Growth and developmental milestones, particularly gross motor abilities, may be helpful in evaluating the plausibility of reported injury mechanisms. The family history should include consanguinity, known metabolic abnormalities, fractures in related family members, hearing impairment, connective tissue disorders and dental hypoplasia.
Any infant or child presenting with a skeletal injury of unclear cause must have a thorough physical examination. Documentation should include:. Ask for an indirect ophthalmological examination by an ophthalmologist in all children with a head injury concerning for inflicted trauma. If the child has evidence of multisystem trauma or concern for an underlying medical condition, additional medical testing may be indicated .
The skeletal survey SS is the cornerstone of radiographic investigation for fractures of unclear cause because it provides valuable information about bone health and may identify occult skeletal injury. While the yield for positive findings decreases past age 2 years, the clinician should consider imaging children between 2 and 5 years of age when there is a strong likelihood of occult inflicted injury. Guidelines for appropriate SS imaging in children are outlined by the American College of Radiology and endorsed by the American Academy of Pediatrics .
The SS must be performed in a complete and technically adequate manner to optimize identification of both underlying medical conditions and skeletal injuries that are not clinically evident e. A bone scan may be helpful when used in conjunction with the skeletal survey.
However, due to poor sensitivity for metaphyseal, epiphyseal and skull fractures, a bone scan alone should not be used for diagnosis .
Review of skeletal imaging by a paediatric radiologist is recommended. While not all skeletal injuries discovered on radiographic imaging require medical intervention, they may be important for determining injury cause. If the initial SS is negative or equivocal and maltreatment remains a concern, a follow-up SS should be conducted approximately 2 weeks later . In the case of a positive initial SS, follow-up images may identify additional injuries and contribute valuable information on healing and timing of injury. Consider omitting images of the skull, pelvis and lateral spine in follow-up studies, because injuries to these areas are typically identified on the initial series and eliminating them later reduces radiation exposure .
Consider neuroimaging for all infants presenting with fractures and suspected maltreatment. Additional imaging studies may be indicated when laboratory evaluation raises concern for abdominal injury.
Healing of musculoskeletal injuries occurs on a continuum, generally with a predictable progression of radiographic signs in young children. Findings include soft-tissue swelling, periosteal reaction, callus formation and remodelling. Estimating the age of skeletal trauma is important for identifying inconsistencies in the presenting history related to injuries found on physical examination or radiologic studies.
Time frames for dating long bone fractures are broad and demonstrate significant overlap . The presence of fractures of different ages suggests multiple injury events at different times. The documentation of all historical and clinical information should be detailed, using clear, objective language and conclusions. When the clinical, radiographic or laboratory information suggests a pre-existing medical condition, a consult with genetics, metabolic diseases or endocrinology may be particularly helpful Figure 2.
An orthopedic consultation is often necessary to assist with fracture immobilization, surgical management or concerns regarding suboptimal healing or growth. Any reasonable suspicion of child maltreatment requires reporting to the appropriate child protection authorities, in all provinces and territories in Canada. Consultation with clinicians who have expertise in child maltreatment paediatrics can assist medical management, facilitate collaboration between health care providers and community child protection investigators, and help with medico-legal aspects of communication and documentation.
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