for humeral shaft fractures (N = 34). Based on the charts, the physicians ranked each case as probable not abuse, probable abuse, or indeterminate. Of the 34 cases, 62% were unanimously ranked or ranked by three of the four physicians as probable not abuse, and 20% were ranked as probable abuse by one or more of the physicians. The remainder of the cases (18%) were ranked as indeterminate by two or more of the physi- cians. Kemp et al. [19] reviewed 32 published studies of child abuse victims younger than 18 years and found that supracondylar fractures were reported to be more likely associated with accidental injury, specifically falls.
Worlock et al. [5] found that in the 35 infants and tod- dlers with nonaccidental injuries (150 total fractures), only one fracture was identified as supracondylar. Of the 116 infants and toddlers with accidental injuries (135 fractures), 13 fractures were identified as supracondy- lar. Despite reporting a lower occurrence of supracon- dylar fractures in nonaccidental cases than accidental cases (3:70), Strait et al. [22] cautioned against dismiss- ing supracondylar fractures as accidental based on fracture type alone.
Accidental tibial fractures require special attention.
Childhood accidental spiral tibial (CAST) fractures typi- cally are isolated spiral fractures located on the mid and distal regions of the tibial shaft that occur with rel- atively low levels of force. Often the spiral fracture is oriented superolaterally to inferomedially. CAST frac- tures are most common in children aged 2–6 years. The mechanism is a torque or rotational force applied to the lower extremity associated with a fall or an immo- bilized foot [35]. CAST fractures are easily recognized on radiographs. Toddler fractures, which are consid- ered a subset of CAST fractures, are nondisplaced oblique or spiral fractures of the distal tibia that are dif- ficult to recognize on radiographs [8]. Mellick and Ressor [35] conducted a 14-month prospective study during which ten CAST fractures were recognized, as well as a retrospective study of 5 years of social work service records of child abuse cases. Of the ten frac- tures examined during the prospective study, nine were a result of accidental injury and were found in children ranging in age from 21 to 44 months. Only one fracture resulted from nonaccidental injury; the infant was 9 months old (nonambulatory). During the retro- spective study of the child abuse cases, 33 cases were found with skeletal injury, only three of which were CAST fractures. Of the three CAST fractures, one was in a 2-month-old who on subsequent hospital visits had rib fractures. The other two cases involved a 19-month- old and a 17-month-old, and the suspicion of child abuse and neglect was based on an inability to exclude child abuse and a previous allegation of leav- ing the child unattended. Of interest, Schwend et al.
[26] found that spiral femoral shaft fractures were com- mon in ambulatory children and described them as analogous to toddler fractures. They stated that femo- ral shaft fractures may occur at relatively low-energy levels, including low-level simple falls, and are nonspe- cific for nonaccidental injury.
Figure 5-30. Supracondylar humeral fracture observed in a 3-year-old female. Note the SPNBF along the shaft proximal to the fracture. The cause of death was multiple blunt trauma of the head, torso, and extremities with fractures; lacerations of the heart, liver, and mesentery; and subdural hemorrhage. The manner was classified as homicide.
Figure 5-29. Healing torus fracture. Shown is a healing torus frac- ture (arrow) of the distal femoral metaphysis observed in a 1-month-old female. Note the frayed appearance of the periphery of the physeal surface; the physeal surface is intact.
The cause of death was classified as hypoxic–ischemic encephalopathy due to multiple blunt force injuries, including skull fractures and subarachnoid hemorrhage; the manner was classified as homicide.
Summary
Long bone fractures are highly variable in type and location. The mechanism of the injury often can be reconstructed from the features of the fracture. The con- sensus among researchers is that no long bone fracture
is pathognomonic for nonaccidental injury. The age of the child, inconsistencies between history and clinical presentation, delay in treatment, and injuries of various ages often are more telling than the fracture itself.
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The ultimate goal of skeletal injury analysis in cases of suspected child abuse is to reconstruct the child’s life history with regard to the number, extent, and timing of the traumatic episodes. Recognizing and interpreting fracture distribution patterns through- out the body enable the anthropologist to move from the myopic assessment of the isolated fracture to the comprehensive evaluation of the inflicted injury that may have multiregional involvement. In turn, assessment of the stage(s) of healing observed throughout the skeleton often leads to an estimate of the minimum number of traumatic episodes and the age(s) of the injury. However, variation in healing rates associated with the type of bone injured and the extent of the initial injury must be recognized.