non-accidental injury and the orthopaedic surgeon. peter worlock newcastle general hospital
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Non-accidental injury and the Orthopaedic Surgeon.
Peter Worlock
Newcastle General Hospital
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Role of doctors:
• Be aware of problem.• Recognise unusual injury patterns.• Initiate investigation.
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Soft tissue injuries:
• Bites.• Burns.• Bruising.
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Bites:
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Bruising:
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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
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Soft tissue injuries – NAI:
• Head/face injuries present in 60%.• Lumbar injuries common under age of 5 years.
Roberton et al, 1982
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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.
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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
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Age - and sex-specific incidence rates – # caused by AI:
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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
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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
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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
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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
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Delay in presentation:
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Patterns of # (aged < 18 months):
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Patterns of # (aged 19 – 60 months):
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Metaphyseal ‘chip’ #:
•Said to be “classic” pattern of # in NAI.
•Less common than often thought.
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Rib #:
•Present in 54% of children in NAI group.
•None seen in AI group.
•All diagnosed on skeletal survey, after abuse suspected.
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Spiral # of humeral shaft:
•Seen in 9 out of 35 children in NAI group.
•None seen in AI group (p<0.001)
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Skull # after NAI:
•Multiple or complex #.•Involvement of more than one bone.•Non-parietal #.•Depressed #.•‘Growing’ #.
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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
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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
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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.
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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.
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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
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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.
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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.
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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.
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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.