Although the Skeletal Atlas of Child Abuse focuses on pediatric trauma, much of the information in the text and photographs of this book is applicable to the analysis of skeletal trauma in general. Even rarer is the involvement of forensic anthropologists in unsolved child abuse cases, such as the practice of the HCIFS.
Acknowledgments
Contents
Skeletal Examination Method
Radiographic Examination
Negative anterior-posterior chest radiograph showing the skeletal elements of the chest and abdomen of a 5-month-old male. Usually, close-up x-rays of the joints are taken with a collimated beam to reduce x-ray scattering and facilitate examination of the bones before examining the skeleton.
Skeletal Examination
Incisions made to examine the subcutaneous tissue of the back, buttocks, arms, and legs during autopsy are extended through the periosteum to the surface of the long bone, and the overlying muscle is resected, taking care to minimize the amount of soft tissue involved. destruction. The reflection of the upper muscles is followed by a longitudinal cut through the periosteum, along the stem of each bone.
Documentation and Analysis
To evaluate the scapulae, the infraspinatus and supraspinatus muscles are cut along the medial margin of the scapula and along the scapular spine. The periosteum is incised along the same axes, and the periosteal elevator is used to reflect the periosteum in the same manner as the overlying muscle tissue.
Skull Fractures
This chapter describes the manifestation of skeletal damage to the subadult skull as seen during the skeletal examination process. The chapter first provides an overview of pediatric cranial fracture types and continues with a discussion of pediatric cranial anatomy as it relates to the interpretation of skull fractures, a review of the literature regarding the manifestation of fractures to the various regions of the skull, and a discussion of the distinctions between accidental and non-accidental fractures; it concludes with a number of recent anthropological examples from the Harris County Institute of Forensic Sciences (HCIFS).
Skull Fracture Types
The Pediatric Cranium
Fusion of the metopic suture begins anteriorly at the bridge of the nose and progresses posteriorly. Pneumatization of the frontal sinus begins in the postnatal period, and expansion continues until puberty.
Skull Fracture Location
64] found that the parietal bone fractures in pediatric pigs in their sample initiated at locations remote from the impact site, regardless of age. 64] used porcine models to investigate the change in the susceptibility of the parietal bone to fracture with age.
Vault Fractures
Post-processing image of the endocranial surface of the occipital bone of the subject in fig. The left side of the neck bone depicted in fig. a) Note the fracture (arrowhead) and another defect (arrow).
Facial Bone Fractures
A close-up endocranial view of the anterior cranial fossa in the individual shown in the figure. Reduced anterior protrusion of the nose relative to the arch is associated with a lower incidence of nasal bone fractures in children than in adults [81, 82].
Cranial Base Fractures
Ferreira PC, Amarante JM, Silva PN, et al.: Retrospective study of 1251 maxillofacial fractures in children and adolescents. Geddes JF, Hackshaw AK, Vowles GH, et al.: Neuropathology of traumatic head injury in children: patterns of brain injury.
Rib Fractures
Rib Fracture Location
Posterior Rib Fractures
After treatment, an avulsion fracture of the rib head is shown; the view is of the articular surface (same individual as shown in Figure 3.2). Note the thickened cortical bone (arrows) and the rim of bony callus over the articular surface of the rib head.
Posterolateral Rib Fractures
The cause of death was classified as blunt trauma to the head with skull fractures and brain injuries, the wise as murder. The cause of death was classified as blunt trauma to the head and torso with bilateral rib and scapular fractures, visceral lacerations and multiple contusions, the manner as homicide.
Anterolateral Rib Fractures
Anterior Rib Fractures
Acute partial fracture of the thoracic surface of the right sixth rib in a 2-month-old female. Acute partial fracture of the thoracic surface of the left fourth rib in a 3-year-old female.
Cardiopulmonary Resuscitation Fractures
The incomplete buckle fractures (arrows) are located in the anterolateral to anterior region of the rib and are interpreted as the result of anterior to posterior compression of the midchest. The decrease in cortical bone density is consistent with the history of prematurity of the deceased (born after 27 weeks of gestation).
First Rib Fractures
Summary
In this chapter, there is a holistic approach to the trunk with a description of fractures of the neck, thoracic skeleton, pectoral ring, and thoracolumbar and sacral regions of the spine. The thoracic skeleton consists of the thoracic vertebra, ribs, sternum and costal cartilage that connects the sternum to the ribs (Fig. 4.1–4.3).
Fractures of the Vertebral Column, Sternum,
The robust lumbar column acts as a strong base for weight transfer to the pelvic girdle and lower extremities and encloses the end of the spinal cord. The flexibility of the bone and cartilage structure of this area allows expansion and contraction of the chest during breathing movements.
Scapulae, and Clavicles
The anatomy of the pectoral girdle provides the mobility required for directional movement of the arm. The chest plate and internal organs have been removed as part of the examination procedure.
Vertebral Fractures
The authors noted that the most common location of the fracture was the L1-L2 segment. 7] were located in the T11-T12 segment and involved vertebral body compression with associated listhesis.
Fractures of the Sternum
Fractures of the Scapula
Two incompletely healed transverse fractures, one at the medial border and one at the lateral border (arrow), are present in the left scapula of a 3-year-old female. The cause of death was classified as multiple blunt trauma to the head, torso and extremities with fractures; lacerations of the heart, liver and mesentery; and subdural hemorrhage.
Fractures of the Clavicle
SPNBF is present in the lateral third of the left clavicle of a 3-year-old male (arrow). The cause of death was assessed as blunt force trauma to the head and the manner as homicide.
Classic Metaphyseal Lesions
The interpretation of the forces associated with the fracture depends on the location, type and extent of the fracture. A torus (or buckle) fracture, in which the cortical bone balloons out, is typically the result of a compressive force applied through the long axis of the bone.
Long Bone Fractures
The cause of death was classified as blunt trauma to the head with skull fracture and brain contusion, the manner as homicide. The cause of death was classified as blunt trauma to the head with skull fracture and brain contusion, the manner as homicide.
Shaft, Metaphyseal, and Epiphyseal Fractures
The cause of death was classified as blunt trauma to the head, the manner as homicide. The cause of death was classified as blunt trauma to the head with subdural hematoma and skull fracture, the manner as homicide.
Accidental Versus Nonaccidental Injury
Jones JCW, Feldman KW, Bruckner JD: Child abuse in infants with physical injuries of the proximal femur. On the other hand, estimation of the healing phase(s) observed in the entire skeleton often leads to an estimate of the minimum number of traumatic episodes and age(s) of injury.
Healing
The ultimate goal of skeletal injury analysis in cases of suspected child abuse is to reconstruct the child's life history in terms of the number, extent, and timing of traumatic episodes. However, differences in healing rates related to the type of bone damaged and the extent of the initial injury must be considered.
Healing and Interpretation
Subperiosteal new bone formation (SPNBF) is the bone formed by the cambium layer of the periosteum, as mentioned earlier. In the calcified cartilage zone, the chondrocytes die and the thin septum of the chondrocytes is calcified by deposits of hydroxyapatite.
Stages and Rates of Healing
The cause of death was classified as blunt head injury, the cause of death as homicide. The cause of death was classified as multiple blunt force injuries to the torso, and therefore as homicide.
Healing of the Skull
The deceased survived in hospital for 37 days after the date of injury. a) Ectocranial surface of the occiput.
Healing Rate
The decedent had a history of repeated blunt force trauma to the chest over a 2-week period. The cause of death was classified as multiple blunt force trauma, the manner being homicide. a, b) Healing fracture of the humerus with rapid callus formation in a 2-month-old female.
Interpretation
Note the splitting of the bone, especially in panel (b), and the buckling, especially in panel (c). Incomplete compression fractures observed in the anterior area of the rib of the individual shown in Fig.
Natural Disease May Mimic Child Abuse
Sequelae of Prematurity
Note the porosity on the inner surface of the rib body at the end of the sternum. The sternal end of the left fourth rib of a 5-month-old male with an extensive history of preterm delivery shows marked cortical fragility with exposure of trabeculae.
Osteogenesis Imperfecta
Syndromes Resembling Osteogenesis Imperfecta
The multiple fenestrations visible in the skull specimens from a 3-month-old male are typical of the poor bone quality characteristic of OI or SROI.
Infantile Cortical Hyperostosis (Caffey Disease)
Caffey disease predisposes to the diaphysis of the long bones (including the clavicles), mandible and ribs, but may also affect the scapulae asymmetrically [21, 26]. The prevalence of Caffey disease is unclear because it appears to be relatively rare, but cases can be difficult to diagnose.
Hypophosphatasia (Rathbun Syndrome)
The cause of death was classified as asphyxia due to detachment of a ventilator from the tracheostomy used to treat quadriplegia after blunt trauma with cervical spine injury; the way it was classified as an accident.
Menkes Disease
Mucolipidosis Type II
Sickle Cell Disease
Hypovitaminosis D and Rickets
The normal physical surface of the left distal radius of a 5-month-old individual (a) and the atypical. Comparison of typical and atypical development of the physical surface. a) Normal development of the physical surface is seen in the left ulna, fibula, and radius of a 2-month-old individual.
Metabolic Bone Disease in Short Bowel Syndrome and Biliary Atresia
Koo WW, Sherman R, Succop P, et al.: Consecutive bone mineral content in small preterm infants with and without fractures and rickets. Arita JH, Faria EC, Peruchi MM, et al.: Menkes disease as a differential diagnosis of child abuse.
Index
