The detection of significant fractures in suspected infant abuse

Abstract

In infants coming to post-mortem, histopathology is more sensitive than SS for the detection of clinically significant fractures. In children suspected of non-accidental injuries but with negative or equivocal SS, sampling of the anterior and posterior end of ribs 5-8 and the bones around the knee for histological examination could reveal clinically unsuspected fractures and significant evidence of physical abuse. 71% of infants showed evidence of old fractures typical of non-accidental injury.

Prevalence and distribution of occult fractures on skeletal surveys in children with suspected non-accidental trauma imaged or reviewed in a tertiary Dutch hospital

“…Rib fractures were most prevalent detected occult fractures in our cohort. In accordance with the literature mid ribcage rib fractures were most common found [18,19]. This suggests that the skeletal survey is pivotal in the detection of rib fractures, especially because these fractures can easily be missed on a regular chest X-ray [3,4].…”

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

“…posterior ribs, limb bone metaphyses) carry a high correlation with NAI and have causational implications. 10,12,[14][15][16] The causational significance of demonstrating fracture types is well reported, 11,14,17 and we recently demonstrated 13 how routine sampling of apparently unfractured bones might disclose key, unsuspected fractures.…”

“…posterior rib and metaphyseal) that are commonly missed. [10][11][12] Further evidence of fracture can be obtained at autopsy, 9,13 but naked eye examination also misses key fractures.…”

“…It is accepted that post-mortem histological examination of infant bones can detect fractures not seen radiologically. 9,11,13,14 Optimising detection of fractures is key, as multiple fractures and fractures of certain bones/parts of bones (e.g. posterior ribs, limb bone metaphyses) carry a high correlation with NAI and have causational implications.…”

Broken bones and irresponsible testimony?

“…The idea that certain lesions are likely to represent abuse is widely believed but is based on circular reasoning (Berthold et al, 2018;Chauvin-Klimoff, Allard-Dansereau, & Colbourne, 2018;Flaherty et al, 2014;Högberg, Andersson, Högberg, & Thiblin, 2019;Paine, Fakeye, Christian, & Wood, 2019). Indeed, much current research is directed at maximizing the evidence of abuse (Raynor, Konala, & Freemont, 2018;Shelmerdine et al, 2018;Wood et al, 2018).…”