A 6-month-old black female infant was evaluated in consultation after admission to the hospital. The child was not responsive to painful stimuli and was on a respirator. Her left knee was swollen but stable on examination. She had good distal pulses. She had a moderately swollen head. Figure 1 is an x-ray of the knee region. Your diagnosis is:
* Bacterial meningitis
* Acute fulminate osteomyelitis
* Battered child syndrome
* Gaucher's disease
Figure I shows subperiosteal new bone formation of the medial aspect of the femur and tibia. There is a fracture of the metaphyseal break of the distal femur medially. Figure 2 depicts a parietal skull fracture. These injuries were caused by child abuse. The child has required several months of hospitalization and has sustained brain damage.
It is important that orthopedists recognize child abuse and treat it appropriately, up to 10% of cases can lead to death.1 The key to making the diagnosis is a careful history and a thorough examination. Usually the history relating to the injury is confusing, and does not account for the extent of injury involved.2 There is often evidence of previous injury which should make the physician suspicious. The patterns of child abuse vary from neglect and sexual abuse, to blunt trauma to the head, chest, or abdomen. Extremity injuries and burns are also common.3
In a recent series, one-half of all femur fractures in children under five years of age and two-thirds of all femur fractures in children under one year of age were related to child abuse.4 A spiral fracture may indicate abuse as this injury is sustained by a twisting mechanism. Other radiographic signs of abuse include fractures in different stages of healing, periosteal reaction from subperiosteal bleeds, and metaphyseal fragmentation.5
The goal of management is to protect the child from further injury. All states have statutes requiring that suspected abuse be reported,5 many areas have child protection or advocacy teams to assist in management. Because child abuse can lead to permanent injury or death, admission to the hospital for investigation is sometimes necessary.
1. Kempe CH, Silverman FN, Steele BF, et al: The battered child syndrome. JAMA 1962; 181:17-24.
2. O'Neill JA, Meacham WF. Griffin PP. et al: Patterns of injury in the battered child syndrome. Trauma 1973. 13.332-339.
3. Caffey J: Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. AJR 1946; 56:163-173.
4. Gross RH: Child abuse; Arc you recognizing it when you sec it? Contemporary Orthopedics 1980; 2(9):676-678.
5. Gross RH , Stranger M; Causative factors responsible for femoral fractures in infants and young children. Pediatric Orthopedics 1983; 3.341-343.
Section Editor: William A. Grana, MD