Historical background  

Tardieu in 1860 (King 1988) described the

lesions found during the autopsy of children
such as burns and associated these features
with “battered children”. In 1946 Caffey (King
1988) reported the association of subdural
haematoma and long bone fractures. Reports
then became more frequent, but it was only
after mainstream use of the definition of
Kempe (1962) of the term “battered child
syndrome” that the problem started to be
debated in public, and legal measures put in
place in various countries.

Key points

• Child abuse has been reported in the

literature since the 1860s but it was
not until the 1960s that there was
public and legal awareness

Definition
The initial definition by Kempe implied direct
physical abuse and has since been broadened
to psychological and sexual abuse, emotional
and medical neglect. If a child is harmed by
the lack of appropriate treatment for a specific
condition (for example : parents or caretaker
who refuse physical therapy and casting for a
clubfoot) , it is considered as medical neglect
and necessitates the same general approach
as direct physical abuse.

Key points

• Kempe’s definition has been

broadened to include psychological
and sexual abuse, emotional and
medical neglect.

Epidemiology
The exact number of children being neglected
or abused is impossible to determine since
numerous cases are undiagnosed or
unreported. A general estimate is that 1 to 1.5
% of all children are abused (Akbarnia 1996).
Child abuse is universal and found in all races
and classes. All children can be abused but
the majority are small children, especially
below the age of one. Boys and girls are
equally affected. Stepchildren are at greater
risk. Once abused there is about a 35 % of
chance of “ relapse” and 5 % of death.

Diagnosis
Child abuse diagnosis and thus management
is often delayed or undiagnosed.

Environmental elements

The physician
Emergency room physicians, paediatricians,
general practitioners and orthopaedic
surgeons are often in the first line in the
discovery of an abused child. To be able to
distinguish “normal” physical injuries from
neglect or abuse, the physician needs to first
of all have a high level of suspicion in all
injuries involving young children, especially if
the caretaker gives no clear explanation. Less
experienced physicians might also feel
uncomfortable with these more “general” and
“emotional” situations. Some physicians might
be more reluctant to report cases from higher
social classes. Over diagnosis can bring
conflicts in the future patient-doctor
relationships.

Despite all these examples of the difficulties

involved with only “suggesting” the possibility
of an abused child, the orthopaedic surgeon
must go further than the simple fracture
treatment and each fracture needs an
appropriate explanation in a child.

Medical history
There is not one simple clue but again
physicians need to have a level of suspicion
when the trauma history given by the
caretaker is vague, changes when repeated,
or does not fit the lesions found. The caretaker
can also report that he/she did not see the
incident or that the child just started to
complain. They can also be reluctant to give
explanations and delay bringing in the child for
medical treatment. Another element of
suspicion is if they come from another part of
town/country as they may already be known to
staff in local hospitals (and not because “this
hospital is better” which is the explanation they
will give you).

Caretaker

Parents are the most common abuser but any

caretaker can be involved. Again there is not a
single easily recognised pattern. The abuser
can be overly aggressive towards the medical
staff, raise lots of question, or refuse
investigations on the child. They can also look
overly protective of the child and very
concerned. Difficult social situations, disrupted
families, drug or alcohol abuse, and disabilities
can be involved but are not always present.

Key points

• Parents are the most common

abuser.

• There are no simple patterns to

recognize.

• Abusive parents may act over

concerned.
Child

The child also has different attitudes from very

compliant to aggressive. Girls and boys are
equally affected. Stepchildren and
handicapped children are more at risk. On the
other hand the abused child might show
“developmental delay” due to the abuse. In
one family, all children can be abused but it
can also affect only one of them

The physician should be able to recognize any

inappropriate behaviour in the caretakers or
the child.

Clinical findings
The orthopaedic surgeon will be confronted to
the bony lesions, but will have to look for other
“clues” if an abused child is suspected.

Soft tissue lesions

Physical examination will reveal bruises,

burns, lacerations, and scars. Again some of
these have usual, normal explanations but one
will have to make the differences between
“normal” bruises from falls: elbows, shins,
knees and inflicted ones: buttocks, perineum,
trunk. The same is true for lacerations and
scars. Cigarette burns are quite characteristic.
Burns are seen in 10% of abused children,
and some reports suggest as high as 20%
(Galleno 1982). It is also useful to determine
the timing of the bruises and soft tissue
lesions: one or more episodes?

Photographs and appropriate documentation

of these lesions is crucial.

Head injuries

The head and face are often injured since they

are quite easy targets. The usual weapon is
the human hand.

Violent shaking of a baby or young child can

be particular deleterious with cerebral oedema
or subdural haematoma and is known as the “
shaken baby syndrome”.

Thus in any child where abuse or neglect is

suspected, a good neurological examination is
necessary. On the other hand, in any child with
unexplained neurological signs, abuse has to
be suspected. Skull X-ray are part of the
general skeletal survey, but quite often there is
no skull fractures, only internal lesions. In the
acute phase, CT scans will help and MRI will
show later on the chronic neurologic damage.

Internal injuries

Internal injuries are often the cause of death in

child abuse. Younger children are more often
affected. Death is due to the gravity of these
lesions and the fact that the child is brought
late to the emergency room. Any internal
organ can be injured.

Bony lesions
Although some fracture type or pattern are
more often seen in child abuse, there is not
one “absolute” sign of abuse, it will have to be
added to the other clinical and general
findings.

Fracture Patterns- Radiological Findings

Multiple age fractures and an unclear history

will raise suspicion. However King (1988)
reported that one single fracture was found in
50 % of his series of abused children. Bone
scintigraphy as well as X-rays of the entire
skeleton need to be done to look for fractures
(healed or not). These tests will be very helpful
in the young child unable to express himself
(Akbarnia 1976).

One has to suspect abuse in lower extremity

fractures in non-weight-bearing children, in the
association of posterior ribs fractures with long
bone fractures, in the metaphyseal “corner
fracture” (Kleinman et al 1986).

All other combinations are possible. Some

fractures are more specific: for example a
metaphyseal corner fracture is caused by
pulling forceful on an extremity. They need
good quality X-rays to be seen.

The following list gives an overview on the

degree of suspicion based on the type of
fracture. Again any of them can be seen, even
the regular common fractures (but then with a
suspicious history) (Kleinman 1987)

Highly suspicious fractures:

• Metaphyseal fractures

• Posterior rib fractures

• Scapular fractures

• Spinous process fractures

• Sternal fractures

Suspicious fractures:

• Multiple fractures

• Different age fractures

• Epiphyseal separations

• Vertebral body injuries

• Complex skull fractures

Regular common fractures:

• Clavicular fractures

• Long bone shaft fractures

 • Linear skull fractures

Fracture Dating

Although variations are of course present, it is

quite helpful to date fractures. The following
table gives a timetable of radiographic
changes (Kleinman 1987)

Lesion Early Peak Late

Soft tissue 2-5 days 4-10 10-21 days

days
Periosteal 4-10 10-14 14-21 days

new bone days days

Loss of 10-14 14-21

fracture line days days

definition
   
Soft callus 10-14 14-21

days days
Hard callus 14-21 21-42 42-90 days

days days
Remodelling 3 months 1 year 2 years till

epiphyseal

closure

   

Differential Diagnosis

Child abuse will have to be differentiated from a long list of

a possible other underlying pathology: milder forms of
osteogenesis imperfecta (Sillence 1981), scurvy, rickets,
leukaemia, septic arthritis, osteomyelitis, neurological
disorders (osteoporosis in cerebral palsy,
myelomeningocele , polyomyelitis) , metastatic
neuroblastoma, congenital indifference to pain, stress
fractures, osteopetrosis, and congenital syphilis.

Treatment

Physical treatment

The child needs to be hospitalised for thorough work-up.

The physical treatment of the different injuries is similar to
the general practice for the same lesions.
For example, fracture care is similar, as with regular
fractures, nevertheless the situation might be more complex
with the legal and social issues that will have to be raised.

Legal and social issues

The management of child abuse involves the diagnosis, the

medical treatment and the appropriate social and legal
measures. To be able to address the legal issues it is
mandatory to document the lesion: good medical records
with descriptions of the clinical examinations, social
workers reports, photographs, X-ray, CT-scan, bone scan.

Legal issues vary from country to country, nevertheless the

primary goal is to protect the child from further abuse.
Hospital stay will thus not only be necessary for the full
work-up but also to give time to work out the situation with
the social workers and the appropriate “ teams” and local
legal system.

If possible the child will be returned to his family with

counselling to the abusive caretaker, but this will not always
be possible and if necessary the child will be placed in a
foster home

Key points

• Legal issues vary from country to country,

nevertheless the primary goal is to protect the
child from further abuse

Conclusion
The role of the physician and orthopaedic surgeon is to
think of the possibility of child abuse in specific clinical
conditions, to hospitalise the child for work-up and
treatment, and to alert the appropriate authorities.