Histological ageing of fractures in infants: a practical algorithm for assessing infants suspected of accidental or non‐accidental injury

Abstract

Aims This study is the first to systematically document histological features of fractures of known age in infants (≦12 months). It has been used to develop a tabulated database specifically to guide histopathologists to age fractures in children considered to have suffered accidental or non‐accidental injury ( NAI ). Currently in the United Kingdom there are insufficient pathologists with experience in histological ageing of fractures to meet the medicolegal need for this examination. This study provides a practical tool that will allow those skilled paediatric and forensic pathologists currently involved in assessing infants for evidence of accidental or non‐accidental injury a basis for extending their assessment into this area of unmet need. Methods and results One hundred and sixty‐nine fractures of known age at death were obtained from 52 anonymised infants over a period of 32 years (1985–2016 inclusive). Sections stained using haematoxylin and eosin (H&E) and Martius scarlet blue ( MSB ) were used to identify specific histological features and to relate them to fracture age. In 1999 the data were entered into a tabulated database for fractures accumulated between from 1985 to 1998 inclusive. Thereafter cases were added, and at 2‐yearly intervals the accumulated data were audited against the previous database and adjustments made. Conclusions This paper describes the final data set from the 2017 audit. The study was terminated at the end of 2016, as there had been no material changes in the data set for three consecutive audits.

Infantile rib fractures at autopsy: a marker of antemortem trauma or resuscitation artefact?

“…He was therefore of the view that these findings should not be used to discriminate between true invivo injury and peri-mortem injury. Another key observation in James' study is the demonstration of 'empty lacunae'which had been previously been considered by some authors to represent a marker of vitality at the time of injury, implying osteocyte necrosis 8 in the cortical/trabecular bone at the edge of CPR-related fractures. As such, it is concluded that the observation of 'empty lacunae' is therefore not necessarily a feature indicative of the ante-mortem nature of a fracture.…”

“…The forensic pathologist needs to be able to assist the Court where possible by narrowing the time‐period when a fracture was sustained, as well as the probable mechanism of causation. By carefully studying the histological findings in bone the age of fractures can be determined within a time‐frame, 8 as well as the presence or absence of metabolic changes that may have a bearing on the nature of the force needed to produce a fracture 2–4 …”

The role of the forensic anthropologist in the pediatric autopsy: Interpretations, contributions, and challenges

“…Marks et al (2009) have also suggested that it may be possible to use the histological measurement of SPNBF to estimate TSI. Naqvi, Raynor, and Freemont (2019) correlated the presence of histological features with known date of injury based on a collection of 169 fracture samples from 52 infants collected over a 32-year period. Table 2 provides the histological features by observed time interval, although some features varied in timing based on fracture location (Naqvi et al, 2019).…”

“…Rib cut axially and stained with hematoxylin-eosin (H&E). Arrow indicating ossifying soft callus on the pleural surface of the rib (L = lateral; M = medial) T A B L E 2 Correlation of histological characteristics with known time since injury according toNaqvi et al (2019) Note: h = hours; d = days.…”

Rib histology after unsuccessful cardiopulmonary resuscitation in infants suffering sudden death from natural causes; implications for injury mechanism and timing

“…In an article in this journal 10 in the context of infant fracture histology, the claim was made that haemorrhage into the fracture gap, periosteum or marrow cavity may be used to differentiate a fracture occurring in life from one occurring during CPR or after death, and that the absence of osteocyte nuclei in the bone margins of the fracture indicates osteocyte necrosis, and the passage of at least 1 h between fracture and death. It is of concern that none of the cases described in that article sustained fractures at the time of death or after death; the article did not provide objective evidence of its claims that: ‘it is generally accepted that postmortem fractures (including CPR‐induced) do not bleed significantly’; ‘our experience is that [osteocyte necrosis in cortical/trabecular bone at fracture edges] is never seen in postmortem fractures’; or that ‘we have redefined antemortem haemorrhage to include significant medullary or periosteal haemorrhage with or without RBC in the cortical fracture line’ 10 . These claims were made without objective validation from cases or the medical literature, and no reference was made to the body of literature conflicting with the authors’ claims.…”