Non-Accidental Injury

Epidemiology

• Uncommon
• Crosses socio-economic and cultural boundaries
• Probably under diagnosed
• Important to recognise (but difficult)
• Small proportion of children presenting with fractures
• Commonly have occult fractures

History

• Important to recognise (but difficult)
• Risk Factors
  • Twins,
  • unplanned pregnancies,
  • lower socio-economic status,
  • children with special needs,
  • pre-term babies
• Age – Younger more likely with key ages of less than 2 and 1
• Developmental age
• Mechanism
  • Appropriate behaviour
• History of previous injury
• Medical problems
• Rare causes predisposing to fractures
  • Bone and mineral disease, Osteogenesis imperfecta

Examination

• General findings
  • altered level of consciousness,
  • difficulty in breathing,
  • seizures,
  • failure to thrive.
• Specific orthopaedic features
  • Assessment of
    • pain,
    • swelling,
    • deformity,
    • range of movement
    • altered function/ability to weight-bear
• Bruising
  • Common in mobile children and in NAI
  • Most common clinical finding
  • Look for
    • away from bony prominences,
    • larger bruises,
    • Specific shapes,
    • multiple or clustered configurations

Fractures

• Fractures with high specificity
  • Metaphyseal fractures
  • Rib fractures
  • Scapular fractures
  • Outer-end clavicle fractures
  • Fractures of different ages
  • Vertebral fractures or subluxation
  • Digital injuries in non-mobile children
  • Bilateral fractures
  • Complex skull fractures
• Frequent fractures but with low specificity
  • Mid-clavicular fractures
  • Simple linear skull fractures
  • Single long-bone fractures

Long bones and NAI

• Femur fractures – under 1
• Tibia and fibula under 18 months
• Any Humeral fracture under 15 months
• Humeral spiral fractures commonly associated with NAI
  • Diaphysis 4 X more common than metaphysis
  • Epiphysis rare
  • Metaphyseal fractures are uncommon in infants
  • Think NAI

M>Metaphyseal fractures

• Uncommon under 2
• Indirect forces
  • Acceleration – deceleration
• Associated in neonatal period
  • Classic corner and bucket handle #’s
  • Occur through the weak zone

Inves>Investigations

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XRays

• to confirm fracture
• To rule out NAI

Blood Tests

• Consider biochemical tests, tests for osteogenesis imperfecta

Skeletal survey

• Periodic review and monitoring of callus formation
• Experienced radiologist

Bone scan

• Metaphyseal fractures
  • Poor sensitivity – growth
• Diaphyseal fractures
  • High sensitivity

Dual modalities

• Including CT should be considered

Conclus>Conclusions

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Literature is poor evaluating orthopaedic features of NAI

Retrospective studies = BIAS to NAI

Almost no quality comparative prospective epidemiological studies

Highlighted with metaphyseal fractures

High risk groups not studied appropriately

Multidisciplinary group

Take ho>Take home message

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Think about NAI

Involve pediatricians if concerned (multidisciplinary approach)

Non ambulant and children under 1 year with fractures

Multiple fractures

Fracture sights and patterns