Documente Academic
Documente Profesional
Documente Cultură
CLINICAL REPORT
be difficult to visualize radiographi- to the bone, whereas spiral fractures down several steps and landing with 1
cally. CMLs commonly heal without are caused by torsion or twisting of leg folded or twisted underneath
subperiosteal new bone formation or a long bone along its long axis. Obli- a child can lead to excessive torsional
marginal sclerosis. They can heal que fractures are caused by a combi- loading of the femur and a spiral
quickly and be undetectable on plain nation of bending and torsion loads.37 fracture.46 In ambulatory children,
radiographs in 4 to 8 weeks.31 Torus or buckle fractures are the re- noninflicted femoral fractures have
sult of compression from axial loading been described in children who fell
Fractures With Moderate Specificity along the length of the bone. Although while running or who fell and landed
for Abuse earlier studies suggested that spiral in a split-leg position.43
Although many children who have fractures should always raise suspi- A fracture of the humeral shaft in a child
been abused will have only a single cion for child abuse,12 more recent younger than 18 months has a high
fracture,34 the presence of multiple studies do not show that any partic- likelihood of having been caused by
fractures, fractures of different ages ular fracture pattern can distinguish abuse.15,49,50 In contrast, supracondylar
and/or stages of healing, and com- between abuse and nonabuse with fractures in ambulatory children are
plex skull fractures have moderate absolute certainty.16,38 usually noninflicted injuries resulting
specificity for physical abuse. In ad- Falls are common in childhood.39 Short from short falls.15
dition, epiphyseal separations, verte- falls can cause fractures, but they Physicians should also be aware of
bral body fractures, and digital rarely result in additional significant a particular mechanism reported to
fractures have moderate specificity injury (eg, neurologic injury).11,40–42 In produce a noninflicted spiral-oblique
for abuse. The presence of multiple a retrospective study of short falls, fracture of the humerus in 1 case
fractures or fractures of different parents reported that 40% of the report.51 When the young infant was
ages can be signs of bone fragility children before 2 years of age had rolled from the prone position to the
but should also evoke consideration suffered at least 1 fall from a height of supine while the child’s arm is ex-
of child abuse. Besides the predictive between 6 inches and 4 feet. Approx- tended, the torsion and stress placed
value of the particular pattern of imately one-quarter of these children on the extended arm appeared to
fractures, many other factors, such suffered an injury; bruises were the cause a spiral-oblique fracture of the
as the history and the child’s age, most common injury observed.43 midshaft of the humerus.
must be considered when de- The femur, humerus, and tibia are the Linear skull fractures of the parietal
termining whether the injury was most common long bones to be in- bone are the most common skull
inflicted. jured by child abuse.1,34 Femoral fracture among young children, usu-
fractures in the nonambulatory child ally children younger than 1 year.13 A
Common Fractures With Low are more likely caused by child short fall from several feet onto
Specificity for Child Abuse abuse, whereas these fractures in a hard surface can cause a linear,
Long bone fractures (other than CMLs), ambulatory children are most com- nondiastatic skull fracture.19,52 The
linear skull fractures, clavicle fractures, monly noninflicted.10,16,43–45 majority of linear skull fractures are
and isolated findings of subperiosteal Certain femur fractures may occur as not inflicted.53 By contrast, complex or
new bone formation have low speci- a result of a noninflicted injury in young bilateral skull fractures are typical of
ficity for child abuse. In contrast, the children. Several studies have demon- nonaccidental trauma.
single long bone diaphyseal fracture is strated that a short fall to the knee may
the most common fracture pattern produce a torus or impacted transverse Syndromes, Metabolic Disorders,
identified in abused children.1,13,34 fracture of the distal femoral meta- Systemic Disease
An understanding of the extent and diaphysis.46,47 Oblique distal femur met- Preexisting medical conditions and
type of load that is necessary to cause aphyseal fractures have been reported bone disease may make a child’s
a particular long bone fracture can in children playing in a stationary ac- bones more vulnerable to fracture.
help to determine whether a specific tivity center, such as an Exersaucer Some conditions may manifest skele-
fracture is consistent with the injury (Evenflo, Picqua, OH).48 tal changes, such as metaphyseal ir-
described by the caregiver.35,36 Trans- In both ambulatory and nonambulatory regularity and subperiosteal new
verse fractures of the long bones are children, under some circumstances, bone formation. These entities should
caused by the application of a bending falls on a stairway can cause a spiral be considered in the differential di-
load in a direction that is perpendicular femoral fracture. For example, a fall agnosis of childhood fractures.
vitamin D insufficiency and deficiency inflicted and noninflicted fractures oc- months of age, because fetal copper
and concluded that radiographic ra- curring in these children. At the same stores are sufficient for this length
chitic changes were uncommon and time, children with disabilities are at an of time. In addition, human milk and
very mild. In this population, the increased risk of being maltreated.82–84 formula contain sufficient copper to
reported fracture prevalence was When multiple or recurrent fractures prevent deficiency. Psychomotor re-
zero.72 occur in a disabled child, a trial change tardation, hypotonia, hypopigmentation,
In a study of 45 young children with in caregivers may be indicated to de- pallor, and a sideroblastic anemia are
radiographic evidence of rickets, termine whether the fractures can be some of the characteristic findings of
investigators found that fractures oc- prevented. This is an extreme in- copper deficiency in infants. Radiologic
curred only in those infants and tod- tervention and should be reserved for changes that should lead to further
dlers who were mobile.77 Fractures unusual circumstances.63 evaluation for possible deficiency
were seen in 17.5% of the children, include cupping and fraying of the
and these children were 8 to 19 Scurvy metaphyses, sickle-shaped metaphyseal
months of age. The fractures involved spurs, significant demineralization, and
Scurvy is caused by insufficient intake
long bones, anterior-lateral and lat- subperiosteal new bone formation.
of vitamin C, which is important for the
eral ribs, and metatarsal and meta- synthesis of collagen. Although rare
physeal regions. The metaphyseal today because formula, human milk, Menkes Disease
fractures occurred closer to the di- fruits, and vegetables contain vitamin Menkes disease, also known as
aphysis in the background of florid C, scurvy may develop in older infants Menkes kinky hair syndrome, is a rare
metaphyseal rachitic changes and and children given exclusively cow congenital defect of copper metabo-
did not resemble the juxtaphyseal milk without vitamin supplementation lism.90 Menkes disease is an X-linked
corner or bucket handle pattern of and in children who eat no foods recessive condition and occurs only in
the CML. In infant fatalities in which containing vitamin C.85–87 Although boys. Although it has many of the
abuse is suspected, rachitic changes scurvy can result in metaphyseal features of dietary copper deficiency,
appear to be rare histologically.78 changes similar to those seen with anemia is not associated with Menkes
child abuse, other characteristic bone disease. Metaphyseal fragmentation
Osteomyelitis changes, including osteopenia, in- and subperiosteal new bone forma-
Osteomyelitis in infants can present as creased sclerosis of the zones of tion may be observed on radiographs,
multiple metaphyseal irregularities provisional calcification, dense epiph- and the findings may be difficult to
potentially resembling CMLs.79 Typically, yseal rings, and extensive calcification distinguish from fractures caused by
the lesions become progressively lytic of subperiosteal and soft tissue hem- abuse.91 Other signs of Menkes dis-
and sclerotic with substantial sub- orrhages, will point to the diagnosis ease include sparse, kinky hair, cal-
periosteal new bone formation. Other of scurvy. varial wormian bones, anterior rib
signs of infection are often present, flaring, failure to thrive, and de-
such as fever, increased erythrocyte Copper Deficiency velopmental delay. A characteristic
sedimentation rate, elevated C-reactive finding is tortuous cerebral vessels.
Copper plays a role in cartilage for-
protein concentration, and elevated Intracranial hemorrhage can occur in
mation. Copper deficiency is a rare
white blood cell count. Menkes disease but has not been
condition that may be complicated by
reported in infants with copper de-
bone fractures. Preterm infants are
Fractures Secondary to ficiency.
born with lower stores of copper than
Demineralization From Disuse term infants, because copper is ac-
Any child with a severe disability that cumulated at a faster rate during the Systemic Disease
limits or prevents ambulation can be at last trimester.88 Copper insufficiency Chronic renal disease affects bone
risk for fractures secondary to disuse may be observed in children with metabolism because children with
demineralization, even with normal severe nutritional disorders, for ex- chronic renal disease may develop
handling.80,81 The fractures are usually ample, liver failure or short gut syn- a metabolic acidosis that interferes
diaphyseal rather than CMLs. Often, drome.89 This deficiency is not likely with vitamin D metabolism. Chronic
these fractures occur during physical to be observed in full-term children renal disease can cause renal osteo-
therapy and range-of-motion exercises. younger than 6 months of age or dystrophy resulting in the same ra-
It can be difficult to distinguish between preterm infants younger than 2.5 diographic changes as nutritional
predispose to fractures are impor- neck, or trunk should raise suspicion type I collagen and may identify the
tant. The physician should inquire for child abuse.105,106 The child should mutation to guide testing of other
about previous injuries including be examined for other injuries caused family members.107 Some of the less
bruises and determine the child’s de- by child abuse, in addition to signs of common forms of OI are OI types IIB
velopmental abilities, because chil- other medical conditions associated and VII, CRTAP; OI type VI, FKBP10; OI
dren who are not yet mobile are much with bone fragility. Blue sclerae are type VIII, LEPRE1; OI type IX, PPIB; OI type
more likely to have fractures caused seen in certain types of OI. Sparse, X, SERPINH1; OI type XI, SP7; OI type XII,
by abuse. kinky hair is associated with Menkes SERPINF1; and OI type XIII, BMP1. DNA
disease. Dentinogenesis imperfecta is sequencing can be performed using
Family History occasionally identified in older chil- genomic DNA isolated from peripheral
A family history of multiple fractures, dren with OI. blood mononuclear cells or even sa-
early-onset hearing loss, abnormally liva, whereas the biochemical analysis
developed dentition, blue sclera, and of type I collagen requires a skin bi-
Laboratory Evaluation
short stature should suggest the opsy. Doing both DNA analysis and
The clinical evaluation should guide skin biopsy is not indicated in most
possibility of OI.
the laboratory evaluation. In children cases. Consultation with a pediatric
with fractures suspicious for abuse, geneticist may be helpful in deciding
Social History serum calcium, phosphorus, and al- which children to test and which test
The physician should obtain a com- kaline phosphatase should be reviewed, to order.108
plete psychosocial history, including although alkaline phosphatase may be
asking who lives in the home and who elevated with healing fractures. The
has provided care for the child. The physician should consider checking Imaging Approach
history should inquire about intimate serum concentrations of parathyroid Children younger than 2 years with
partner violence, substance abuse hormone and 25-hydroxyvitamin D, as fractures suspicious for child abuse
including drugs and alcohol, mental well as urinary calcium excretion (eg, should have a radiographic skeletal
illness, and previous involvement with random urinary calcium/creatinine survey to look for other bone injuries
child protective services and/or law ratio) in all young children with or osseous abnormalities.109 Addi-
enforcement. fractures concerning for abuse, but tional fractures are identified in ap-
these levels should certainly be proximately 10% of skeletal surveys,
Physical Examination assessed if there is radiographic ev- with higher yields in infants.110 Skeletal
The child should have a comprehensive idence of osteopenia or metabolic surveys may be appropriate in some
physical examination, and the growth bone disease. Screening for abdomi- children between ages 2 and 5 years,
chart should be carefully reviewed. nal trauma with liver function studies depending on the clinical suspicion
Abnormal weight may suggest neglect as well as amylase and lipase con- of abuse. If specific clinical findings
or endocrine or metabolic disorders. centration should be performed when indicate an injury at a particular
Any signs or symptoms of fractures, severe or multiple injuries are iden- site, imaging of that area should
such as swelling, limitation of motion, tified. A urinalysis should be per- be obtained regardless of the child’s
and point tenderness should be formed to screen for occult blood. age.
documented. The physician should do Serum copper, vitamin C, and ceru- The American College of Radiology has
a complete skin examination to look loplasmin concentrations should be developed specific practice guidelines
for bruises and other skin findings considered if the child is at risk for for skeletal surveys in children.111
because bruises are the most common scurvy or copper deficiency and has Twenty-one images are obtained, in-
injury caused by child abuse. The radiographic findings that include cluding frontal images of the appen-
majority of children with fractures do metaphyseal abnormalities. dicular skeleton, frontal and lateral
not have bruising associated with the If OI is suspected, sequence analysis views of the axial skeleton, and obli-
fracture; the presence or absence of of the COL1A1 and COL1A2 genes that que views of the chest. Oblique views
such bruising does not help to de- are associated with 90% of cases of of the chest have been shown to in-
termine which fractures are caused by OI as well as other genes associated crease the sensitivity, specificity, and
child abuse.103,104 Bruising in a child with less common autosomal- accuracy of the identification of rib
who is not yet cruising or bruising in recessive forms of OI may be more fractures.112 A full 4 skull series should
unusual locations, such as the ears, sensitive than biochemical tests of be obtained if there are concerns of
should be evaluated for maltreat- groups and across all racial and ethnic Emalee G. Flaherty, MD, FAAP
ment.131 In a study of 795 siblings in groups. Many of these diagnoses are John M. Leventhal, MD, FAAP
James L. Lukefahr, MD, FAAP
400 households of a child who had complex. If a physician is uncertain Robert D. Sege MD, PhD, FAAP
been abused or neglected, all sib- about how to evaluate an injury or if
lings in 37% of households and some they should suspect a fracture was LIAISONS
siblings in 20% of households had caused by child abuse, they should Harriet MacMillan, MD – American Academy of
suffered some form of maltreat- consult a child abuse pediatrician Child and Adolescent Psychiatry
Catherine M. Nolan, MSW, ACSW – Administration
ment.132 In this study, which included or multidisciplinary child abuse team for Children, Youth, and Families
all manifestations of maltreatment, to assist in the evaluation, particu- Linda Anne Valley, PhD – Centers for Disease
siblings were found to be more at larly if the child is nonambulatory Control and Prevention
risk for maltreatment if the index or younger than 1 year of age. 134 In
child suffered moderate or severe certain circumstances, the physician STAFF
maltreatment. In addition to a careful will need to consult an orthopedist, Tammy Piazza Hurley
evaluation, imaging should be consid- endocrinologist, geneticist, or other
ered for any siblings younger than 2 subspecialists. SECTION ON RADIOLOGY EXECUTIVE
years, especially if there are signs of COMMITTEE, 2012–2013
All US states, commonwealths, and
Christopher I. Cassady, MD, FAAP, Chairperson
abuse. territories have mandatory reporting Dorothy I. Bulas, MD, FAAP
requirements for physicians and John A. Cassese, MD, FAAP
DIAGNOSIS other health care providers when Amy R. Mehollin-Ray, MD, FAAP
Maria-Gisela Mercado-Deane, MD, FAAP
When evaluating a child with a frac- child abuse is suspected. Physicians
Sarah Sarvis Milla, MD, FAAP
ture, physicians must take a careful should be aware of and comply with
history of any injury event and the reporting requirements of their
STAFF
then determine whether the mechan- state. Typically, the standard for Vivian Thorne
ism described and the severity and making a report is when the reporter
timing are consistent with the injury “suspects” or “has reason to believe”
SECTION ON ENDOCRINOLOGY
identified (see Table 3).133 They must that a child has been abused or EXECUTIVE COMMITTEE, 2012–2103
consider and evaluate for possible di- neglected. Sometimes determining Irene N. Sills, MD, FAAP, Chairperson
agnoses in addition to other signs or whether that “reasonable belief” or Clifford A. Bloch, MD, FAAP
symptoms of child abuse. A careful “reasonable suspicion” standard has Samuel J. Casella, MD, MSc, FAAP
Joyce M. Lee, MD, FAAP
evaluation for other injuries is im- been met can be nuanced and com- Jane Lockwood Lynch, MD, FAAP
portant because the presence of ad- plex. The physician should keep in Kupper A. Wintergerst, MD, FAAP
ditional injuries that are associated mind that incontrovertible proof of
with child abuse increases the likeli- abuse or neglect is not required by STAFF
hood that a particular fracture was state statutes, and there may be Laura Laskosz, MPH
inflicted.16,43 It is important to re- cases in which it is reasonable to
member that even if a child has an consult with a child abuse pediatri- SECTION ON ORTHOPEDICS EXECUTIVE
underlying disorder or disability that cian about whether a report should COMMITTEE, 2012–2013
be made. Richard M. Schwend, MD, FAAP, Chairperson
could increase the likelihood of J. Eric Gordon, MD, FAAP
a fracture, the child may also have Norman Y. Otsuka, MD, FAAP
been abused because children with LEAD AUTHOR Ellen M. Raney, MD, FAAP
disabilities and other special health Emalee G. Flaherty, MD, FAAP Brian A. Shaw, MD, FAAP
Brian G. Smith, MD, FAAP
care needs are at increased risk of
Lawrence Wells, MD, FAAP
child abuse.83,84 Physicians should Paul W. Esposito, MD, USBJD Liaison
COMMITTEE ON CHILD ABUSE AND
keep an open mind to the possibility of NEGLECT, 2012–2013
abuse and remember that child Cindy W. Christian, MD, FAAP, Chairperson STAFF
abuse occurs in all socioeconomic James E. Crawford-Jakubiak, MD, FAAP Niccole Alexander, MPP
41. Lyons TJ, Oates RK. Falling out of bed: 55. Wallis GA, Starman BJ, Zinn AB, Byers PH. 70. Gordon CM, Feldman HA, Sinclair L, et al.
a relatively benign occurrence. Pediatrics. Variable expression of osteogenesis Prevalence of vitamin D deficiency among
1993;92(1):125–127 imperfecta in a nuclear family is healthy infants and toddlers. Arch Pediatr
42. Hansoti B, Beattie T. Can the height of fall explained by somatic mosaicism for a le- Adolesc Med. 2008;162(6):505–512
predict long bone fracture in children thal point mutation in the alpha 1(I) gene 71. Greenspan A. Orthopedic Imaging: A
under 24 months? Eur J Emerg Med. 2005; (COL1A1) of type I collagen in a parent. Am
Practical Approach. 4th ed. Philadelphia,
12(6):285–286 J Hum Genet. 1990;46(6):1034–1040
PA: Lippincott Williams & Wilkins; 2004
43. Thomas SA, Rosenfield NS, Leventhal JM, 56. Barsh GS, Byers PH. Reduced secretion of
72. Perez-Rossello JM, Feldman HA, Kleinman
Markowitz RI. Long-bone fractures in structurally abnormal type I procollagen
PK, et al. Rachitic changes, deminer-
young children: distinguishing accidental in a form of osteogenesis imperfecta.
Proc Natl Acad Sci USA. 1981;78(8):5142– alization, and fracture risk in healthy
injuries from child abuse. Pediatrics. infants and toddlers with vitamin D
1991;88(3):471–476 5146
57. Sprigg A. Temporary brittle bone disease deficiency. Radiology. 2012;262(1):234–
44. Loder RT, O’Donnell PW, Feinberg JR. Epi- 241
demiology and mechanisms of femur versus suspected non-accidental skeletal
injury. Arch Dis Child. 2011;96(5):411–413 73. Slovis TL, Chapman S. Vitamin D in-
fractures in children. J Pediatr Orthop.
58. Greeley CS, Donaruma-Kwoh M, Vettimattam sufficiency/deficiency—a conundrum.
2006;26(5):561–566
M, Lobo C, Williard C, Mazur L. Fractures at Pediatr Radiol. 2008;38(11):1153
45. Baldwin K, Pandya NK, Wolfgruber H,
diagnosis in infants and children with 74. Slovis TL, Chapman S. Evaluating the data
Drummond DS, Hosalkar HS. Femur frac-
osteogenesis imperfecta. J Pediatr Orthop. concerning vitamin D insufficiency/
tures in the pediatric population: abuse
2013;33(1):32–36 doi:10.1097/BPO.1090- deficiency and child abuse. Pediatr
or accidental trauma? Clin Orthop Relat
b1013e318279c318255d Radiol. 2008;38(11):1221–1224
Res. 2011;469(3):798–804
59. Singh Kocher M, Dichtel L. Osteogenesis 75. Jenny C. Rickets or abuse? Pediatr Radiol.
46. Pierce MC, Bertocci GE, Janosky JE, et al.
imperfecta misdiagnosed as child abuse. 2008;38(11):1219–1220
Femur fractures resulting from stair falls
J Pediatr Orthop B. 2011;20(6):440–443 76. Schilling S, Wood JN, Levine MA, Langdon
among children: an injury plausibility
60. Gahagan S, Rimsza ME. Child abuse or D, Christian CW. Vitamin D status in
model. Pediatrics. 2005;115(6):1712–1722
osteogenesis imperfecta: how can we tell? abused and nonabused children younger
47. Haney SB, Boos SC, Kutz TJ, Starling SP. Pediatrics. 1991;88(5):987–992
Transverse fracture of the distal femoral than 2 years old with fractures. Pediat-
61. Ablin DS, Sane SM. Non-accidental in- rics. 2011;127(5):835–841
metadiaphysis: a plausible accidental
jury: confusion with temporary brittle
mechanism. Pediatr Emerg Care. 2009;25 77. Chapman T, Sugar N, Done S, Marasigan J,
bone disease and mild osteogenesis
(12):841–844 Wambold N, Feldman K. Fractures in
imperfecta. Pediatr Radiol. 1997;27(2):
48. Grant P, Mata MB, Tidwell M. Femur frac- 111–113 infants and toddlers with rickets. Pediatr
ture in infants: a possible accidental eti- Radiol. 2010;40(7):1184–1189
62. Knight DJ, Bennet GC. Nonaccidental injury
ology. Pediatrics. 2001;108(4):1009–1011 in osteogenesis imperfecta: a case report. 78. Perez-Rossello JM, McDonald AG, Rosenberg
49. Pandya NK, Baldwin KD, Wolfgruber H, J Pediatr Orthop. 1990;10(4):542–544 AE, Ivey SL, Richmond JM, Kleinman PK.
Drummond DS, Hosalkar HS. Humerus 63. Jenny C; Committee on Child Abuse and Prevalence of rachitic changes in deceased
fractures in the pediatric population: an Neglect. Evaluating infants and young infants: a radiologic and pathologic study.
algorithm to identify abuse. J Pediatr children with multiple fractures. Pediat- Pediatr Radiol. 2011;41(suppl 1):S57
Orthop B. 2010;19(6):535–541 rics. 2006;118(3):1299–1303 79. Ogden JA. Pediatric osteomyelitis and
50. Strait RT, Siegel RM, Shapiro RA. Humeral 64. Backström MC, Kuusela A-L, Mäki R. Met- septic arthritis: the pathology of neonatal
fractures without obvious etiologies in abolic bone disease of prematurity. Ann disease. Yale J Biol Med. 1979;52(5):423–
children less than 3 years of age: when is Med. 1996;28(4):275–282 448
it abuse? Pediatrics. 1995;96(4 pt 1):667– 65. Naylor KE, Eastell R, Shattuck KE, Alfrey AC, 80. Whedon GD. Disuse osteoporosis: physio-
671 Klein GL. Bone turnover in preterm logical aspects. Calcif Tissue Int. 1984;36
51. Hymel KP, Jenny C. Abusive spiral frac- infants. Pediatr Res. 1999;45(3):363–366 (suppl 1):S146–S150
tures of the humerus: a videotaped ex- 66. Harrison CM, Johnson K, McKechnie E. 81. Presedo A, Dabney KW, Miller F. Fractures
ception. Arch Pediatr Adolesc Med. 1996; Osteopenia of prematurity: a national in patients with cerebral palsy. J Pediatr
150(2):226–227 survey and review of practice. Acta Pae- Orthop. 2007;27(2):147–153
52. Laskey AL, Stump TE, Hicks RA, Smith JL. diatr. 2008;97(4):407–413
82. Westcott H. The abuse of disabled chil-
Yield of skeletal surveys in children ≤18 67. Amir J, Katz K, Grunebaum M, Yosipovich
months of age presenting with isolated dren: a review of the literature. Child Care
Z, Wielunsky E, Reisner SH. Fractures in
skull fractures. J Pediatr. 2013;162(1):86– Health Dev. 1991;17(4):243–258
premature infants. J Pediatr Orthop. 1988;
89 8(1):41–44 83. Sullivan PM, Knutson JF. The association
53. Wood JN, Christian CW, Adams CM, Rubin between child maltreatment and dis-
68. Bugental DB, Happaney K. Predicting in-
DM. Skeletal surveys in infants with iso- fant maltreatment in low-income families: abilities in a hospital-based epidemiolog-
lated skull fractures. Pediatrics. 2009;123 the interactive effects of maternal attri- ical study. Child Abuse Negl. 1998;22(4):
(2). Available at: www.pediatrics.org/cgi/ butions and child status at birth. Dev 271–288
content/full/123/2/e247–e252 Psychol. 2004;40(2):234–243 84. Sullivan PM, Knutson JF. Maltreatment
54. Byers PH, Steiner RD. Osteogenesis 69. Keller KA, Barnes PD. Rickets vs. abuse: and disabilities: a population-based epi-
imperfecta. Annu Rev Med. 1992;43:269– a national and international epidemic. demiological study. Child Abuse Negl.
282 Pediatr Radiol. 2008;38(11):1210–1216 2000;24(10):1257–1273
in suspected infant abuse. AJR Am J Clin Endocrinol Metab. 2011;96(10):3160– tigators. Prevalence of abusive injuries in
Roentgenol. 2010;195(3):744–750 3169 siblings and household contacts of phys-
126. Bachrach LK, Sills IN; Section on Endocri- 129. Gordon CM, Baim S, Bianchi M-L, et al; ically abused children. Pediatrics. 2012;
nology. Clinical report—bone densitome- International Society for Clinical Densi- 130(2):193–201
try in children and adolescents. tometry. Special report on the 2007 Pedi- 132. Hamilton-Giachritsis CE, Browne KD. A
Pediatrics. 2011;127(1):189–194 atric Position Development Conference of retrospective study of risk to siblings in
127. Khoury DJ, Szalay EA. Bone mineral den- the International Society for Clinical Den- abusing families. J Fam Psychol. 2005;19
sity correlation with fractures in non- sitometry. South Med J. 2008;101(7):740– (4):619–624
ambulatory pediatric patients. J Pediatr 743 133. Asnes AG, Leventhal JM. Managing child
Orthop. 2007;27(5):562–566 130. Henderson RC, Lark RK, Newman JE, et al. abuse: general principles. Pediatr Rev.
128. Zemel BS, Kalkwarf HJ, Gilsanz V, et al. Pediatric reference data for dual x-ray 2010;31(2):47–55
Revised reference curves for bone min- absorptiometric measures of normal 134. Banaszkiewicz PA, Scotland TR, Myerscough
eral content and areal bone mineral bone density in the distal femur. AJR Am J EJ. Fractures in children younger than age
density according to age and sex for black Roentgenol. 2002;178(2):439–443 1 year: importance of collaboration with
and non-black children: results of the 131. Lindberg DM, Shapiro RA, Laskey AL, Pallin child protection services. J Pediatr Orthop.
bone mineral density in childhood study. J DJ, Blood EA, Berger RP; ExSTRA Inves- 2002;22(6):740–744
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/133/2/e477.full.html