Nonaccidental injury

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London October 2009
Non-accidental injury in the child myths and
misconceptions
J Mark H Paterson FRCS Royal London Hospital
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• Denial "It's not a problem in my practice"
• Fracture morphology is there a specific NAI
  pattern?
• Differential diagnosis

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NAI is a universal problem
Child deaths from maltreatment per 100,000
p.a. Spain 0.1 Greece 0.2 Italy 0.2 Ireland
0.3 Norway 0.3 Netherlands 0.6 Sweden 0.6
Korea 0.8 Australia 0.8 Germany 0.8 Denmark
0.8 Finland 0.8 Poland 0.9 UK 0.9 Switzer
land 0.9 Canada 1.0 Austria 1.0 Japan 1.0
Slovak Republic 1.0 Belgium 1.1 Czech
Republic 1.2 New Zealand 1.3 Hungary 1.3 Fran
ce 1.4 USA 2.4 Mexico 3.0 Portugal 3.7
UNICEF 2003
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Some uncomfortable facts

• 20-30 x safer living with biological married
  parents
• than in other family configurations
• children with single parents have 80 greater
  chance
• of suffering serious injury from neglect or
  abuse than
• those living with both parents
• strong correlation between lower socioeconomic
  class
• and risk of NAI

(NIS-3 USA)
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It was ever thus

• review of cases in Fairbank Radiology Collection
  
• at Royal National Orthopaedic Department
• 15 patients in section labelled
• "Metaphyseal dysplasia and dysostosis" dated
  1927-1956
• 8 / 15 had characteristic features of NAI
• (Horan
  and Beighton, JBJS 1980)

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General features, eg

• Delayed presentation
• Inconsistent history
• Multiple injuries
• Fractures of different ages

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Orthopaedic injuries specific to NAI

• corner or bucket-handle metaphyseal fractures
• spiral vs transverse fractures
• rib fractures
• suspicious lower limb fractures in non-walking
  infant
• suspicious bilateral fractures

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Bucket-handle or corner metaphyseal fracture
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Rib fractures

• do not generally occur during CPR in children
• chest wall has to be squeezed forcefully
• posterior angle fractures strongly indicative of
  NAI
• multiple fractures at different stages of
  healing
• also strongly indicative of NAI

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Differential diagnosis

• infection gt periosteal reaction
• osteogenesis imperfecta
• "transient brittle bone disease"
• Caffey disease
• Menke disease (kinky hair)

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OI fracture
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Caffey disease
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Menke disease
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Menke disease
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Summary

• universal problem
• diaphyseal fracture configuration immaterial
• high index of suspicion
• be familiar with local protocol ( know Child
  Protection lead )
• differential diagnosis