Skip to main content

Advertisement

SpringerLink
Log in

The etiology and significance of fractures in infants and young children: a critical multidisciplinary review

  • Review
  • Published:
Pediatric Radiology Aims and scope Submit manuscript

Abstract

This paper addresses significant misconceptions regarding the etiology of fractures in infants and young children in cases of suspected child abuse. This consensus statement, supported by the Child Abuse Committee and endorsed by the Board of Directors of the Society for Pediatric Radiology, synthesizes the relevant scientific data distinguishing clinical, radiologic and laboratory findings of metabolic disease from findings in abusive injury. This paper discusses medically established epidemiology and etiologies of childhood fractures in infants and young children. The authors also review the body of evidence on the role of vitamin D in bone health and the relationship between vitamin D and fractures. Finally, the authors discuss how courts should properly assess, use, and limit medical evidence and medical opinion testimony in criminal and civil child abuse cases to accomplish optimal care and protection of the children in these cases.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Strouse PJ (2013) ‘Keller & Barnes’ after 5 years — still inadmissible as evidence. Pediatr Radiol 43:1423–1424

    Article  Google Scholar 

  2. Botash AS, Sills IN, Welch TR (2012) Calciferol deficiency mimicking abusive fractures in infants: is there any evidence? J Pediatr 160:199–203

    Article  PubMed  Google Scholar 

  3. Slovis TL, Chapman S (2008) Evaluating the data concerning vitamin D insufficiency/deficiency and child abuse. Pediatr Radiol 38:1221–1224

    Article  PubMed  Google Scholar 

  4. Slovis TL, Strouse PJ, Coley BD et al (2012) The creation of non-disease: an assault on the diagnosis of child abuse. Pediatr Radiol 42:903–905

    Article  PubMed  Google Scholar 

  5. Block RW (1999) Child abuse — controversies and imposters. Curr Probl Pediatr 29:253–272

    Google Scholar 

  6. Sedlak AJ, Mettenburg J, Basena M et al (2010) Fourth national incidence study of child abuse and neglect (NIS–4): report to Congress, executive summary. U.S. Department of Health and Human Services, Administration for Children and Families, Washington, DC

    Google Scholar 

  7. Loder RT, O’Donnell PW, Feinberg JR (2006) Epidemiology and mechanisms of femur fractures in children. J Pediatr Orthop 26:561–566

    Article  PubMed  Google Scholar 

  8. Spady DW, Saunders DL, Schopflocher DP et al (2004) Patterns of injury in children: a population-based approach. Pediatrics 113:522–529

    Article  PubMed  Google Scholar 

  9. Rennie L, Court-Brown CM, Mok JYQ et al (2007) The epidemiology of fractures in children. Injury 38:913–922

    Article  PubMed  Google Scholar 

  10. Leventhal JM, Martin KD, Asnes AG (2008) Incidence of fractures attributable to abuse in young hospitalized children: results from analysis of a United States database. Pediatrics 122:599–604

    Article  PubMed  Google Scholar 

  11. Marlowe A, Pepin MG, Byers PH (2002) Testing for osteogenesis imperfecta in cases of suspected non-accidental injury. J Med Genet 39:382–386

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Ravichandiran N, Schuh S, Bejuk M et al (2010) Delayed identification of pediatric abuse-related fractures. Pediatrics 125:60–66

    Article  PubMed  Google Scholar 

  13. Thorpe EL, Zuckerbraun NS, Wolford JE et al (2014) Missed opportunities to diagnose child physical abuse. Pediatr Emerg Care 30:771–776

    Article  PubMed  Google Scholar 

  14. Wood JN, Feudtner C, Medina SP et al (2012) Variation in occult injury screening for children with suspected abuse in selected US children’s hospitals. Pediatrics 130:853–860

    Article  PubMed  PubMed Central  Google Scholar 

  15. Taitz J, Moran K, O’Meara M (2004) Long bone fractures in children under 3 years of age: is abuse being missed in emergency department presentations? J Paediatr Child Health 40:170–174

    Article  CAS  PubMed  Google Scholar 

  16. Lindberg D, Beaty B, Juarez-Colunga E et al (2015) Testing for abuse in children with sentinel injuries. Pediatrics 136:831–838

    Article  PubMed  Google Scholar 

  17. (2015) Child maltreatment 2013. U.S. Department of Health and Human Services, Washington, DC. https://www.acf.hhs.gov/sites/default/files/cb/cm2013.pdf. Accessed 23 Oct 2015

  18. Flaherty EG, Perez-Rossello JM, Levine MA et al (2014) Evaluating children with fractures for child physical abuse. Pediatrics 133:477–489

    Article  Google Scholar 

  19. Farrell C, Rubin DM, Downes K et al (2012) Symptoms and time to medical care in children with accidental extremity fractures. Pediatrics 129:128–133

    Article  Google Scholar 

  20. Eastwood D (1998) Breaks without bruises. Are common and can’t be said to rule out non-accidental injury. BMJ 317:1095–1096

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Mathew MO, Ramamohan N, Bennet GC (1998) Importance of bruising associated with paediatric fractures: prospective observational study. BMJ 317:1117–1118

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Peters ML, Starling SP, Barnes-Eley ML et al (2008) The presence of bruising associated with fractures. Arch Pediatr Adolesc Med 162:877–881

    Article  PubMed  Google Scholar 

  23. Valvano TJ, Binns HJ, Flaherty EG et al (2009) Does bruising help determine which fractures are caused by abuse? Child Maltreat 14:376–381

    Article  PubMed  Google Scholar 

  24. Wood JN, Fakeye O, Feudtner C et al (2014) Development of guidelines for skeletal survey in young children with fractures. Pediatrics 134:45–53

    Article  PubMed  PubMed Central  Google Scholar 

  25. Manson JE, Bassuk SS (2015) Vitamin D research and clinical practice: at a crossroads. JAMA 313:1311–1312

    Article  CAS  PubMed  Google Scholar 

  26. Welsh P, Sattar N (2014) Vitamin D and chronic disease prevention. BMJ 348:g2280

    Article  PubMed  Google Scholar 

  27. Welsh P, Sattar N (2014) Vitamin D genes and mortality. BMJ 349:g6599

    Article  PubMed  Google Scholar 

  28. Powe CE, Evans MK, Wenger J et al (2013) Vitamin D-binding protein and vitamin D status of black Americans and white Americans. N Engl J Med 369:1991–2000

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Ross AC, Manson JE, Abrams SA et al (2011) The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J Clin Endocrinol Metab 96:53–58

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Christakos S, Hewison M, Gardner DG et al (2013) Vitamin D: beyond bone. Ann N Y Acad Sci 1287:45–58

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Bouillon R, Van Schoor NM, Gielen E et al (2013) Optimal vitamin D status: a critical analysis on the basis of evidence-based medicine. J Clin Endocrinol Metab 98:1283–1304

    Article  Google Scholar 

  32. Shah D, Gupta P (2015) Vitamin D deficiency: is the pandemic for real? Indian J Community Med 40:215–217

    Article  PubMed  PubMed Central  Google Scholar 

  33. Theodaratou E, Tzoulaki L, Zgaga L et al (2014) Vitamin D and multiple health outcomes: umbrella review of systematic reviews and meta-analyses of observational studies and randomized trials. BMJ 348:g2035

    Article  Google Scholar 

  34. Institute of Medicine (2011) Dietary reference intakes for calcium and vitamin D. The National Academies Press, Washington, DC

    Google Scholar 

  35. Wagner CL, Greer FR (2008) Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics 122:1142–1152

    Article  PubMed  Google Scholar 

  36. Misra M, Pacaud D, Petryk A et al (2008) Vitamin D deficiency in children and its management: review of current knowledge and recommendations. Pediatrics 122:398–417

    Article  PubMed  Google Scholar 

  37. Braegger C, Campoy C, Colomb V et al (2013) Vitamin D in the healthy European paediatric population. J Pediatr Gastroenterol Nutr 56:692–701

    Article  CAS  PubMed  Google Scholar 

  38. Alonso MA, Pallavicini ZF, Rodríguez J et al (2015) Can vitamin D status be assessed by serum 25OHD in children? Pediatr Nephrol 30:327–332

    Article  PubMed  Google Scholar 

  39. Schilling S, Wood JN, Levine MA et al (2011) Vitamin D status in abused and nonabused children younger than 2 years old with fractures. Pediatrics 127:835

    Article  PubMed  Google Scholar 

  40. Contreras JJ, Hiestand B, O’Neill JC et al (2014) Vitamin D deficiency in children with fractures. Pediatr Emerg Care 30:777–781

    Article  PubMed  Google Scholar 

  41. Gordon CM, Feldman HA, Sinclair L et al (2008) Prevalence of vitamin D deficiency among healthy infants and toddlers. Arch Pediatr Adolesc Med 162:505–512

    Article  PubMed  PubMed Central  Google Scholar 

  42. Shore RM, Chesney RW (2013) Rickets: part II. Pediatr Radiol 43:152–172

    Article  PubMed  Google Scholar 

  43. Shore RM, Chesney RW (2013) Rickets: part I. Pediatr Radiol 43:140–151

    Article  PubMed  Google Scholar 

  44. Perez-Rosello JM, Feldman HA, Kleinman PK et al (2012) Rachitic changes, demineralization, and fracture risk in healthy infants and toddlers with Vitamin D deficiency. Radiology 262:234–241

    Article  Google Scholar 

  45. Fraser D, Kooh SW, Scriver CR (1967) Hyperparathyroidism as the cause of hyperaminoaciduria and phosphaturia in human vitamin D deficiency. Pediatr Res 1:425–435

    Article  CAS  PubMed  Google Scholar 

  46. Moon RJ, Harvey NC, Davies JH et al (2014) Vitamin D and skeletal health in infancy and childhood. Osteoporos Int 25:2673–2684

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Parfitt AM (2004) Vitamin D and the pathogenesis of rickets and osteomalacia. In: Feldman D, Pike J, Glorieux F (eds) Vitamin D, 2nd edn. Elsevier, London, pp 1029–1048

    Google Scholar 

  48. Chapman T, Sugar N, Done S et al (2010) Fractures in infants and toddlers with rickets. Pediatr Radiol 40:1184–1189

    Article  PubMed  Google Scholar 

  49. Perez-Rossello JM, McDonald AG, Rosenberg AE et al (2015) Absence of rickets in infants with fatal abusive head trauma and classic metaphyseal lesions. Radiology 275:810–821

    Article  PubMed  Google Scholar 

  50. Jenny C (2014) Alternate theories of causation in abusive head trauma: what the science tells us. Pediatr Radiol 44:S543–S547

    Article  PubMed  Google Scholar 

  51. Muhe L, Lulseged S, Mason KE et al (1997) Case-control study of the role of nutritional rickets in the risk of developing pneumonia in Ethiopian children. Lancet 349:1801–1804

    Article  CAS  PubMed  Google Scholar 

  52. Kovacs CS (2011) Fetal mineral homeostasis. In: Glorieux FH, Pettifor JM, Jüppner H (eds) Pediatric bone: biology & diseases. Elsevier, London, pp 271–302

    Google Scholar 

  53. Kovacs CS (2012) The role of vitamin D in pregnancy and lactation: insights from animal models and clinical studies. Annu Rev Nutr 32:97–123

    Article  CAS  PubMed  Google Scholar 

  54. Dabezies EJ, Warren PD (1997) Fractures in very low birth weight infants with rickets. Clin Orthop Relat Res 335:233–239

    PubMed  Google Scholar 

  55. Koo W, Sherman R, Succop P et al (1989) Serum vitamin D metabolites in very low birth weight infants with and without rickets and fractrues. J Pediatr 114:1017–1022

    Article  CAS  PubMed  Google Scholar 

  56. Shore RM (2013) Metabolic bone disease. In: Coley BD (ed) Caffey’s pediatric diagnostic imaging, 12th edn. Saunders, Philadelphia, pp 1523–1534

    Google Scholar 

  57. Fox GN, Maier MK (1984) Neonatal craniotabes. Am Fam Physician 30:149–151

    CAS  PubMed  Google Scholar 

  58. Pettifor JM, Pentopoulos M, Moodley GP et al (1984) Is craniotabes a pathognomonic sign of rickets in 3-month-old infants? S Afr Med J 65:549–551

    CAS  PubMed  Google Scholar 

  59. Kokkonen J, Koivisto M, Lautala P et al (1983) Serum calcium and 25-OH-D3 in mothers of newborns with craniotabes. J Perinat Med 11:127–131

    Article  CAS  PubMed  Google Scholar 

  60. Teotia M, Teotia SP, Nath M (1995) Metabolic studies in congenital vitamin D deficiency rickets. Indian J Pediatr 62:55–61

    Article  CAS  PubMed  Google Scholar 

  61. Al-Senan K, Al-Alaiyan S, Al-Abbad A et al (2001) Congenital rickets secondary to untreated maternal renal failure. J Perinatol 21:473–475

    Article  CAS  PubMed  Google Scholar 

  62. Wang LY, Hung HY, Hsu CH et al (1997) Congenital rickets — a patient report. J Pediatr Endocrinol Metab 10:437–441

    CAS  PubMed  Google Scholar 

  63. Mohapatra A, Sankaranarayanan K, Kadam SS et al (2003) Congenital rickets. J Trop Pediatr 49:126–127

    Article  PubMed  Google Scholar 

  64. Gradus D, Le Roith D, Karplus M et al (1981) Congenital hyperparathyroidism and rickets: secondary to maternal hypoparathyroidism and vitamin D deficiency. Isr J Med Sci 17:705–708

    CAS  PubMed  Google Scholar 

  65. Kovacs CS (2011) Fetus, neonate and infant. In: Feldman D, Pike JW, Adams JS (eds) Vitamin D, 3rd edn. Elsevier, London, pp 625–646

    Chapter  Google Scholar 

  66. (2015) ACR-SPR practice parameter for skeletal surveys in children. American College of Radiology, Reston. http://www.acr.org/Quality-Safety/Standards-Guidelines/Practice-Guidelines-by-Modality/Pediatric. Accessed 23 Oct 2015

  67. Kemp AM, Dunstan F, Harrison S et al (2008) Patterns of skeletal fractures in child abuse: systematic review. BMJ 337:a1518

    Article  PubMed  PubMed Central  Google Scholar 

  68. Kleinman PK, Marks SC Jr, Spevak MR et al (1991) Extension of growth-plate cartilage into the metaphysis: a sign of healing fracture in abused infants. AJR Am J Roentgenol 156:775–779

    Article  CAS  PubMed  Google Scholar 

  69. Caffey J (1972) The parent-infant traumatic stress syndrome (Caffey-Kempe syndrome), (battered babe syndrome). Am J Roentgenol Radium Ther Nucl Med 114:218–229

    CAS  PubMed  Google Scholar 

  70. Duffy SO, Squires J, Fromkin JB et al (2011) Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys. Pediatrics 127:e47–e52

    Article  PubMed  PubMed Central  Google Scholar 

  71. Meyer JS, Gunderman R, Coley BD et al (2011) Appropriateness criteria® on suspected physical abuse — child. J Am Coll Radiol 8:87–94

    Article  PubMed  Google Scholar 

  72. Pandya NK, Baldwin K, Wolfgruber H et al (2009) Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center. J Pediatr Orthop 29:618–625

    Article  PubMed  Google Scholar 

  73. Wood JN, Fakeye O, Mondestin V et al (2014) Prevalence of abuse among young children with femur fractures: a systematic review. BMC Pediatr 14:169

    Article  PubMed  PubMed Central  Google Scholar 

  74. Thomas SA, Rosenfield NS, Leventhal JM et al (1991) Long-bone fractures in young children: distinguishing accidental injuries from child abuse. Pediatrics 88:471–476

    CAS  PubMed  Google Scholar 

  75. Harper NS, Eddleman S, Lindberg DM et al (2013) The utility of follow-up skeletal surveys in child abuse. Pediatrics 131:e672–e678

    Article  PubMed  Google Scholar 

  76. Singh R, Squires J, Fromkin JB et al (2012) Assessing the use of follow-up skeletal surveys in children with suspected physical abuse. J Trauma Acute Care Surg 73:972–976

    Article  PubMed  Google Scholar 

  77. Zimmerman S, Makoroff K, Care M et al (2005) Utility of follow-up skeletal surveys in suspected child physical abuse evaluations. Child Abuse Negl 29:1075–1083

    Article  PubMed  Google Scholar 

  78. Barsness KA, Cha ES, Bensard DD et al (2003) The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma 54:1107–1110

    Article  PubMed  Google Scholar 

  79. Kleinman PK, Marks SC Jr (1996) A regional approach to classic metaphyseal lesions in abused infants: the distal tibia. AJR Am J Roentgenol 166:1207–1212

    Article  CAS  PubMed  Google Scholar 

  80. Kleinman PK, Marks SC, Blackbourne B (1986) The metaphyseal lesion in abused infants: a radiologic-histopathologic study. AJR Am J Roentgenol 146:895–905

    Article  CAS  PubMed  Google Scholar 

  81. Tsai A, McDonald AG, Rosenberg AE et al (2014) High-resolution CT with histopathological correlates of the classic metaphyseal lesion of infant abuse. Pediatr Radiol 44:124–140

    Article  PubMed  Google Scholar 

  82. Thompson A, Bertocci G, Kaczor K et al (2015) Biomechanical investigation of the classic metaphyseal lesion using an immature porcine model. AJR Am J Roentgenol 204:W503–W509

    Article  PubMed  Google Scholar 

  83. Faden MA, Krakow D, Ezgu F et al (2009) The Erlenmeyer flask bone deformity in the skeletal dysplasias. Am J Med Genet A 149A:1334–1345

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  84. Sinigaglia R, Gigante C, Bisinella G et al (2008) Musculoskeletal manifestations in pediatric acute leukemia. J Pediatr Orthop 28:20–28

    Article  PubMed  Google Scholar 

  85. Kogutt MS, Swischuk LE, Fagan CJ (1974) Patterns of injury and significance of uncommon fractures in the battered child syndrome. Am J Roentgenol Radium Ther Nucl Med 121:143–149

    Article  CAS  PubMed  Google Scholar 

  86. (2015) Child abuse prevention. Centers for Disease Control, Atlanta. http://www.cdc.gov/Features/HealthyChildren/. Accessed 23 Oct 2015

  87. Koc F, Oral R, Butteris R (2014) Missed cases of multiple forms of abuse and neglect. Int J Psychiatry Med 47:131–139

    Article  PubMed  Google Scholar 

  88. Jenny C, Hymel KP, Ritzen A et al (1999) Analysis of missed cases of abusive head trauma. JAMA 281:621–626

    Article  CAS  PubMed  Google Scholar 

  89. Lindberg DM, Shapiro RA, Laskey AL et al (2012) Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics 130:193–201

    Article  PubMed  Google Scholar 

  90. McEwen BS (2007) Physiology and neurobiology of stress and adaptation: central role of the brain. Physiol Rev 87:873–904

    Article  PubMed  Google Scholar 

  91. Widom CS (1989) The cycle of violence. Science 244:160–166

    Article  CAS  PubMed  Google Scholar 

  92. Fang X, Brown DS, Florence CS et al (2012) The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse Negl 36:156–165

    Article  PubMed  PubMed Central  Google Scholar 

  93. Moreno JA (2013) What do pediatric healthcare experts really need to know about Daubert and the rules of evidence? Pediatr Radiol 43:135–139

    Article  PubMed  Google Scholar 

  94. Campbell KA, Olson LM, Keenan HT (2015) Critical elements in the medical evaluation of suspected child physical abuse. Pediatrics 136:35–43

    Article  PubMed  Google Scholar 

  95. (2012) ACR appropriateness criteria®: suspected physical abuse – child. American College of Radiology. http://www.acr.org/~/media/300cc40d9d3e4e498bd77074af814c68.pdf. Accessed 23 Oct 2015

  96. Mendelson KL (2005) Critical review of ‘temporary brittle bone disease’. Pediatr Radiol 35:1036–1040

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Radiology, The Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA

    Sabah Servaes

  2. Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA

    Stephen D. Brown

  3. Department of Medical Imaging, Alfred I. duPont Hospital for Children, Wilmington, DE, USA

    Arabinda K. Choudhary

  4. Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA

    Cindy W. Christian & Michael A. Levine

  5. Department of Radiology, Seattle Children’s Hospital, Seattle, WA, USA

    Stephen L. Done

  6. Department of Radiology, Children’s Healthcare of Atlanta, Atlanta, GA, USA

    Laura L. Hayes

  7. Florida International University College of Law, Miami, FL, USA

    Joëlle A. Moreno

  8. Department of Pediatrics, New York University School of Medicine, New York, NY, USA

    Vincent J. Palusci

  9. Department of Medical Imaging, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    Richard M. Shore

  10. Department of Radiology, Wayne State University School of Medicine and Children’s Hospital of Michigan, Detroit, MI, USA

    Thomas L. Slovis

Authors
  1. Sabah Servaes
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Stephen D. Brown
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Arabinda K. Choudhary
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Cindy W. Christian
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Stephen L. Done
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Laura L. Hayes
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Michael A. Levine
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Joëlle A. Moreno
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Vincent J. Palusci
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Richard M. Shore
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Thomas L. Slovis
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sabah Servaes.

Ethics declarations

Conflicts of interest

Dr. Christian and Dr. Palusci provide medico-legal expert work in child abuse cases. All other authors have no disclosures.

Additional information

This review was endorsed by the Society for Pediatric Radiology Board of Directors on Nov. 29, 2015.

Sabah Servaes, Stephen D. Brown, Arabinda K. Choudhary, Laura L. Hayes, and Joëlle A. Moreno are members of the Child Abuse Committee of the Society for Pediatric Radiology.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Servaes, S., Brown, S.D., Choudhary, A.K. et al. The etiology and significance of fractures in infants and young children: a critical multidisciplinary review. Pediatr Radiol 46, 591–600 (2016). https://doi.org/10.1007/s00247-016-3546-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00247-016-3546-6

Keywords

Search

Navigation