Orthopaedic aspects of paediatric non-accidental injury

Effectiveness of Single-Person Reset Fixed System for Pediatric Supracondylar Humeral Fractures: Case Series and a Meta-Analysis

OBJECTIVE

This study examined the feasibility and effectiveness of utilizing the single-person reset fixed system (RFS) for treating pediatric supracondylar humeral fractures (SHFs) to enhance surgical efficiency and reduce manpower requirements.

METHODS

A retrospective analysis of 10 pediatric SHF cases treated with the Single-Person RF was conducted from 2022 to 2023. The primary variables of interest were surgical time, fluoroscopy frequency, postoperative outcomes, and complication rates.

RESULTS

All patients achieved successful single-stage surgical reduction and fixation without additional surgeries. The surgical time was 55 min, with an average fluoroscopy frequency of 11.8 times. Postoperatively, Baumann's Angle ranged from 64 to 81 degrees, indicating restoration of normal joint mobility as Range of Motion (ROM) exceeded 90%. The meta-analysis highlighted the significant advantage of the Single-Person RFS in improving the excellent treatment rate with low heterogeneity.

CONCLUSION

The single-person RFS demonstrates remarkable effectiveness in pediatric SHF treatment, evident through reduced surgical times, decreased fluoroscopy frequency, minimal complications, and positive functional recovery for patients. The findings emphasize the superiority of the single-person RFS in enhancing treatment outcomes, suggesting future optimization and potential broader applications in fracture management.

Divergent interpretations of child abuse in legal judgments: perspectives from clinicians and forensic experts

BACKGROUND

Child abuse in Taiwan is a major societal concern that severely affects the well-being of children. Despite the complexity in detecting abuse, reports of child abuse are increasing, evidenced by a rise in cases and heightened awareness. This study utilizes judicial judgments as a lens to understand the varied interpretations of child abuse by clinical and forensic experts and explores the broader epidemiological trends of such abuse within the declining youth population of Taiwan.

METHODS

We conducted a retrospective study by analyzing official court judgments on child abuse allegations judged from 2008 to 2022 from the online database of Judicial Yuan. Furthermore, the study analyzed demographic factors, injury patterns, and opinions from various experts.

RESULTS

The results reveal that severe criminal cases of child abuse predominantly involve biological fathers as the primary offenders and physical abuse as the most common form of maltreatment. Victims are typically aged less than 5 years, which frequently leads to an unfavorable prognosis. Analysis also highlights the TEN-4-FACESp acronym as a highly predictive indicator of child abuse and underscores the prevalence of abusive head trauma (AHT). Moreover, the findings emphasize ongoing disparities in opinions between forensic medical examiners and clinical physicians, especially in AHT cases, which potentially influences judicial decisions.

CONCLUSIONS

In summary, the study reveals ongoing disagreements between forensic medical examiners and clinical physicians, especially in cases of AHT, which may impact judicial decisions. Promoting consensus through interdisciplinary collaboration and improved communication can aid in revealing the truth in child abuse cases.

Pediatric skeletal injuries in emergency department; an alarm of child maltreatment in Egypt: A cross-sectional study

BACKGROUND

Child physical abuse, a type of child maltreatment (CM), poses a significant global public health concern. Nonaccidental fractures and soft tissue injuries, which encompass any action that directly or indirectly harms a child, are the primary indicators of physical abuse in children.

OBJECTIVE

This study aimed to investigate the prevalence, risk factors, and outcomes of accidental and nonaccidental skeletal fractures in a sample of Egyptian children.

METHODS

A cross-sectional analytical study was conducted between March 2022 and August 2022. A total of 156 children who presented with skeletal injuries and attended Mobarak Central Hospital were enrolled. Patients were subjected to full history taking, complete examination, and investigations. A structured questionnaire was administered to all the legal guardians.

RESULTS

Physical abuse was reported in 22.4 % of cases, while medical neglect was reported in 19.9 % of cases. The incidence of physical abuse was notably higher among children whose fathers were smokers and/or drug addicts (p ≤ 0.05). The most common form of physical abuse was hitting (94.3 %). Among skeletal injuries, fractures were predominant (94.3 %), primarily closed fractures associated with contusions. Fractures of the upper limb accounted for the highest incidence (94.3 %) of skeletal injuries, and 60 % of physically abused children experienced moderate-severity injuries.

CONCLUSION

The most common fracture observed in abused children is the upper limb fracture, typically involving a single bone. Clinicians should be more vigilant in suspecting abuse, even in cases where there is an isolated fracture, and advocate for the development of parental training programs.

Age-specific Patterns of Intimate Partner Violence Related Injuries in US Emergency Departments

PURPOSE

To identify intimate partner violence (IPV)-related injury patterns of U.S. patients of three age groups: <18 years (adolescents), 18-25 years (emerging adults), and >25 years (adults).

METHODS

We performed a nationally representative retrospective review of all patients presenting to U.S. Emergency Department for IPV-related injuries from 2005 through 2020. Demographics and injury patterns were calculated using statistical methods accounting for the weighted stratified data. Main outcomes were injury morphology, mechanism, severity, location, and temporal associations of IPV-related injuries among the three age groups.

RESULTS

There was a higher proportion of female victims, sexual assault cases, and lower trunk injuries among adolescents compared to emerging adults and adults. There was increasing injury severity, fractures, and hospital admissions with increasing age. Adolescents experienced a greater prevalence of fractures of the head, neck, hands, fingers, and distal lower extremity, while trunk fractures increased with age. The peak prevalence of violence-related Emergency Department visits among adolescents was in June and September, with the peak day as Tuesday.

DISCUSSION

Injurious forms of IPV are prevalent across all age groups, with sexual assault cases demonstrably higher among adolescents and increasing severity of injuries as victims age. Identification of age-specific injury patterns will aid health-care professionals and policymakers in developing targeted interventions for adolescents who experience IPV.

Identification and Evaluation of Non-Accidental Trauma in the Pediatric Population: A Clinical Review

Non-accidental trauma (NAT) is a major cause of morbidity and mortality for children around the world and most significantly impacts children under one year of age. Prompt and comprehensive treatment of these children relies on a high index of suspicion from any medical provider that treats pediatric patients. This review discusses those most at risk for experiencing NAT, and common initial presentations, to assist providers in the identification of potential victims. In addition, this review provides guidance on the recommended workup for these patients so that the full extent of associated injuries may be identified and the appropriate healthcare team may be assembled.

Tips from the shop floor: postgraduate doctors working in trauma and orthopaedics

Trauma and orthopaedics is a useful rotation for junior doctors to undertake. Experience in the specialty allows doctors to feel more confident in the diagnosis and treatment of conditions affecting the entire musculoskeletal system. Many junior doctors cover on-calls in trauma and orthopaedics departments, often with no prior specialist experience. This article provides junior doctors with up-to-date information about how to prepare for a placement in trauma and orthopaedics, as well as helpful resources for those interested in a career in trauma and orthopaedics.

Skeletal Surveys in Suspected Non-accidental Trauma: Examining the Yield and Current Clinical Practices at a Regional Referral Center in West Virginia

Introduction Non-accidental trauma (NAT) is a leading cause of pediatric injury and death. When NAT is suspected in children under the age of 24 months, the American Academy of Pediatrics (AAP) recommends using skeletal surveys (SS) to identify acute, healing, or old fractures and to repeat the SS approximately two weeks after initial imaging as acute fractures can sometimes not be seen on initial imaging. In this study, we determined the yield of initial and follow-up SS obtained for suspected NAT in children under the age of 24 months at a regional referral hospital. Methods We reviewed charts of children younger than 24 months who received SS imaging, due to physical abuse suspicion, at our hospital system between 2017 and 2022. We used convenient sampling to examine all SS occurring at the Charleston Area Medical Center Healthcare System. Results A total of 61 of the 126 initial SS showed fractures. Only 9% of children received follow-up SS. Repeat SS performed approximately two weeks after positive initial SS showed signs of healing, including new fractures not reported on the initial scan. Follow-up SS performed within eight weeks after initial negative scans continued to be negative. Lastly, consults from child abuse pediatricians were found to be underutilized as only 48% of patients received consultations. Conclusion Follow-up SS and child abuse pediatrician consults were found to be underutilized. Follow-up SS and consulting child abuse specialists should not be overlooked, irrespective of positive or negative initial SS, to provide optimal management of NAT.

Friends Not Foes: Optimizing Collaboration with Subspecialists

Pediatric orthopedic patients can be complex to manage. As orthopedists plan for possible surgical interventions, consultation with pediatric subspecialists will be necessary. This article discusses the considerations an orthopedist should make when deciding on the timing and the appropriateness of consultation-both preoperatively and perioperatively. Consultation before surgical intervention will especially be useful if the subspecialist will be collaborating in the management of the condition postoperatively (whether inpatient or outpatient). Clear and early consultation in both written and verbal format will facilitate quality and expedite the patient's care.

Paediatric tibial shaft fractures: an instructional review for the FRCS exam

This instructional review presents the literature and guidelines relevant to the classification, management and prognosis of paediatric tibial shaft fractures at a level appropriate for the FRCS exit examination in Trauma and Orthopaedic surgery.

Diagnostic Tools in the Detection of Physical Child Abuse: A Systematic Review

Child abuse is a critical social issue. The orthopedic surgeon's role is essential in noticing signs and symptoms of physical abuse. For this reason, several authors have proposed scoring systems to identify abuse early on and reduce undiagnosed cases. The aim of this systematic review is to overview the screening tools in the literature. In 2021, three independent authors performed a systematic review of two electronic medical databases using the following inclusion criteria: physical child abuse, questionnaire, survey, score, screening tool and predictive tool. Patients who had experienced sexual abuse or emotional abuse were excluded. The risk of bias evaluation of the articles was performed according to the Newcastle-Ottawa Quality Assessment Scale Cohort Studies. Any evidence-level study reporting clinical data and dealing with a physical child abuse diagnosis tool was considered. A total of 217 articles were found. After reading the full texts and checking the reference lists, n = 12 (71,035 patients) articles were selected. A total of seven screening tools were found. However, only some of the seven diagnostic tools included demonstrated a high rate of sensitivity and specificity. The main limits of the studies were the lack of heterogeneity of evidence and samples and the lack of common assessing tools. Despite the multiplicity of questionnaires aimed at detecting validated child abuse, there was not a single worldwide questionnaire for early diagnosis. A combination of more than one test might increase the validity of the investigation.

Pearls and Pitfalls of Thoracic Manifestations of Abuse in Children

Child abuse is a broad term that includes, but is not limited to, physical or emotional harm, neglect, sexual abuse, and exploitation. In 2018 in the United States, there were nearly 700,000 victims of such maltreatment, of which 1700 children died. The majority of deaths occur in infants and toddlers under 3 years of age. While clinical signs and symptoms may raise suspicion for inflicted injury, such as bruising in young infants, imaging often plays a central role in identifying and characterizing nonaccidental trauma. The purpose of this article is to discuss the array of inflicted traumatic injuries to the thorax in children. Rib fractures are among the most common and telling features of physical abuse, especially in infants. The locations of such fractures and differences in appearance while healing will be presented, along with potential mimics and pitfalls. Less typical fractures seen in abuse will also be reviewed, including those of the sternum, clavicle, spine, and scapula. Finally, uncommon injuries to the lungs, heart and esophagus will also be considered.

Modern management of paediatric tibial shaft fractures: an evidence-based update

AIMS

This review provides a summary of recent evidence surrounding the treatment of paediatric tibial shaft fractures and presents an algorithm to aid management of these injuries. This article reviews the relevant anatomy, epidemiology and aetiology of tibial shaft fractures and summarises contemporary treatment principles. Management recommendations and supporting evidence are given for fractures according to age (< 18 months, 18 months-5 years, 6-12 years, and 13-18 years). The relative merits of casting, plate fixation, elastic and rigid intramedullary nailing, and external fixation are discussed. Special attention is paid to the management of open tibial shaft fractures and to complications including infection and acute compartment syndrome.

CONCLUSIONS

There has been a shift away from non-operative management of paediatric tibial shaft fractures over the last 30 years. However, recent evidence highlights that a non-operative approach produces acceptable outcomes when used in simple closed fractures at any age. Operative management may be indicated for unstable fractures where satisfactory alignment cannot be maintained or in specific circumstances including open injuries and polytrauma. Open injuries require urgent assessment by a combined orthopaedic and plastic surgery team at a specialist tertiary centre.

Micro-CT for the examination of paediatric rib injuries: A case series

Cases of child abuse and homicide are amongst the biggest challenges investigators face, with complex evidence bases often strongly contested and reliant on specialist interpretation of the medical evidence. In many cases, this medical evidence includes examination of the deceased's skeleton using different macroscopic and microscopic imaging methods. Rib fractures are a common concern when examining suspicious cases and much research has been conducted on their causes. The role of CPR in particular has been controversial and therefore a clear assessment of the fracture distribution is crucial. Recent studies have shown the benefit of imaging techniques such as Computed Tomography, although the gold standard remains histology. This paper presents three cases of suspected non-accidental rib fractures of infants which had been examined using micro-CT and histology. Micro-CT has been shown to be superior to medical CT as it achieves a greater resolution, making it effective for paediatric post-mortem imaging. Micro-CT observations were compared retrospectively to the histology, which demonstrated that micro-CT found 69% of the fractures identified histologically as well as an additional 22% not identified through histology. As well as complimenting histological analysis, the extent to which micro-CT can enhance the overall examination of paediatric non-accidental injuries is also discussed.

The Role of the Orthopaedic Surgeon in the Identification and Management of Nonaccidental Trauma

Nonaccidental trauma (NAT) has short- and long-term effects on the patient. The importance of identification and management of injuries related to NAT can be vital to the disruption of patterns of abuse and can ultimately save lives. The purpose of this review is to educate the orthopaedic surgeon as the frontline provider in the treatment of these patients. Understanding the risk factors for abuse, sentinel signs on clinical examination, and questionable fracture patterns related to NAT enables providers to better identify and address children at risk of abuse or neglect. Equally as important, understanding pathologic states that can mimic NAT allows the orthopaedic surgeon the tools necessary to address all patients with multiple and/or unexplained fractures. Understanding the legal expectations and protections for practicing orthopaedic surgeons as mandated reporters and the importance of a multidisciplinary approach to intervention in these settings will improve patient experiences and outcomes.

Three-dimensional printed models of the rib cage in children with non-accidental injury as an effective visual-aid tool

Three-dimensional (3-D) printing is gaining terrain in medical education, presurgical evaluation and recently as forensic evidence in court. Physicians, including radiologists, often provide expert testimony in court cases involving children with rib fractures and other injuries concerning for child physical abuse. Effectively communicating the complexities of fractures and other skeletal findings to nonmedical personnel using standard radiology studies can be challenging, especially during medical courtroom testimony. For this reason, we printed two 3-D models of the rib cage from the chest computed tomography (CT) scans of two patients with suspected non-accidental injury. The patients also had available chest radiographs. The DICOM (Digital Imaging and Communications in Medicine) data were 3-D reconstructed and segmented using two attenuation thresholds. We removed unwanted structures and printed them on a commercially available scanner. A pediatric radiologist, blinded to clinical data, reviewed both 3-D models, identified all rib lesions and classified them according to their healing stage. We compared the 3-D models and the chest radiograph against the chest CT as the standard of care. We convened a meeting with the Child Protection Team at out institution to get their feedback and opinions about the models. From our observations of our experts, three spontaneous interactions were observed. Instinctively, the experts picked up and grasped the models, rotating them, feeling them and angling them to better visualize the fractures from multiple angles. The experts expressed a willingness to consider using the models in court.

The Risk of Assuming Abuse in an Infant with an Isolated Metaphyseal Lesion: A Case Report

CASE

The classic metaphyseal lesion, or corner fracture, is considered a strong indicator of nonaccidental trauma. In the present case, the parents brought their 8-month-old boy to a community hospital after he stopped crawling on the right leg. A knee radiograph demonstrated an isolated metaphyseal lesion, which prompted concern for child abuse. The patient was transferred to the nearest academic medical center; the pediatric radiology expert in child abuse determined that the lesion was a normal variant and not the result of abuse.

CONCLUSION

An isolated metaphyseal lesion is not pathognomonic for child abuse, and a thoughtful differential diagnosis should be considered.

Deaths Due to Child Abuse: A 6-Year Review of Cases in The Cook County Medical Examiner's Office

Case files from the Cook County Medical Examiner's Office from 2007 to 2012 were reviewed to analyze homicides due to physical child abuse in children <3 years old. Fatal cases mostly involved younger subjects. Intracranial injuries were the leading cause of death, while death due to extracranial injuries was uncommon. Eyes were involved in most of the cases. Spinal cord was involved in about 1/3 of the cases, mostly in the thoracic area. In some cases, previous injuries were present. There were significant differences in the pattern of injuries between age groups. Subjects showing signs of impact to the head and subjects with no evidence of an impact showed no significant difference in internal injuries. The association of multiple injuries is highly suggestive of child abuse. In suspected child abuse, a postmortem examination including neuropathological, ophthalmological, and radiological information should be always evaluated, together with investigative reports and the medical history.

Changing trends in the management of children's fractures

The management of children's fractures has evolved as a result of better health education, changes in lifestyle, improved implant technology and the changing expectations of society. This review focuses on the changes seen in paediatric fractures, including epidemiology, the increasing problems of obesity, the mechanisms of injury, non-accidental injuries and litigation. We also examine the changes in the management of fractures at three specific sites: the supracondylar humerus, femoral shaft and forearm. There has been an increasing trend towards surgical stabilisation of these fractures. The reasons for this are multifactorial, including societal expectations of a perfect result and reduced hospital stay. Reduced hospital stay is beneficial to the social, educational and psychological needs of the child and beneficial to society as a whole, due to reduced costs.

Missed clavicle fractures on anterior-posterior views of skull X-rays: a retrospective, observational, and descriptive study

OBJECTIVE

The clavicle is almost always seen in skull X-rays of infants. The objectives of this study were to determine how often the clavicle and clavicle fractures are visible but missed on the skull anterior-posterior view (skull AP) of infants and which factors are associated with missing the diagnosis.

METHODS

We retrospectively studied patients aged 1 year or younger who had a skull AP taken for any injury survey at a single urban, academic hospital between April 1999 and July 2012. Outcomes of interest were the numbers and percentages of visible clavicles; clavicle fractures, including missed ones on skull AP; and the factors associated with missing the diagnosis of a clavicle fracture.

RESULTS

Both clavicles were visible in 734 patients (89.6%). Of these, 10 patients (1.4%) had confirmed clavicle fractures, and 6 patients (0.8%) had fractures that were missed at presentation. Although we tried to determine the factors that might be associated with missed diagnoses, including age <6 months, male sex, blocking by guardian's hands, associated skull fractures, and mechanism of injury, none was significantly associated with missed clavicle fractures.

CONCLUSION

The clavicles were recognizable on skull X-rays in most cases. Therefore, one should check the clavicles when reading skull X-rays.

Nonaccidental trauma: guidance for nurses in the pediatric intensive care unit

Each year thousands of children are hospitalized for traumatic injuries associated with physical abuse. Nurses in the pediatric intensive care unit must be knowledgeable and skilled in caring for the physical, psychological, emotional, social, and developmental needs of such children and their families. This article provides direction for pediatric nurses working in the critical care setting. Specifically, it describes the nursing care of children in a pediatric intensive care unit where the mechanism of nonaccidental injury is blunt force to the head, abdomen, or musculoskeletal system, based on standards put forth by the American Association of Critical-Care Nurses.

Pediatric nonaccidental injury: are orthopedic surgeons vigilant enough?

BACKGROUND

Nonaccidental pediatric injuries are major cause of morbidity and mortality, with fractures being second to soft-tissue injuries as the most common presentation. As the orthopedic surgeon might be the only physician an abused child would encounter, the role of the orthopedic surgeon is of great importance. It includes recognition, treatment, and appropriate report of suspected child abuse. The purpose of this study is to examine the attitude and knowledge of orthopedic surgeons treating suspected nonaccidental injuries.

METHODS

Evaluation of orthopedic surgeons included level of knowledge regarding pediatric nonaccidental injury, common practice, and reporting attitudes to Child Protection Services. We specifically examined whether seniority and professional experience had effect on knowledge and performance. Data were collected by a questionnaire distributed to orthopedic surgeons.

RESULTS

The study cohort includes 130 orthopedic surgeons. As much as 62.3% of participating physicians had 10 years or less experience practicing as orthopedic surgeons, and 37.7% had more than 10 years of experience. A mean of 2.39 cases of suspected child abuse was treated over the last year by the physicians that completed the questionnaire. Thirty-five percent of the responders had specific targeted training with respect to the "violence toward minors or helpless reporting obligation law." Of the participating physicians, 89.2% stated that they thought it is the responsibility of the orthopedic surgeons to raise the suspicion for child abuse and refer the child and his/her parents to Child Protection Services. When treating a case of suspected nonaccidental injury, 61.2% of experienced physicians stated that they try to find out what caused the symptoms as opposed to 81.5% of less-experienced physicians (P = 0.011).

CONCLUSIONS

The study findings suggest that many orthopedic surgeons--both senior physicians and less-experienced physicians--can benefit by improved education and training modality related to pediatric nonaccidental injury. More-experienced physicians had lesser awareness and tendency to further investigate cases with suspected nonaccidental injury compared with less-experienced physicians.

LEVEL OF EVIDENCE

Level III-retrospective study.

Child abuse and the legal system: the orthopaedic surgeon's role in diagnosis

BACKGROUND

Orthopaedic surgeons have unique training and experience in diagnosis of fractures, both accidental and nonaccidental. That experience is valuable in identifying physical child abuse and in avoiding false accusations or convictions. Both aspects are important to the welfare of children and their families. The events that follow a report of child abuse are outside the training and experience of most orthopaedic surgeons.

QUESTIONS/PURPOSES

What process follows a report of suspected child abuse? What unexpected outcomes or results occur in this process? Are medical conclusions used in this process consistent with the state of our knowledge?

METHODS

The child abuse legal process is described as experienced by one orthopaedic surgeon. Examples of unexpected problems that occurred in cases that went to trial are described.

CONCLUSIONS

Inappropriate outcomes can result from incomplete or incorrectly applied information. The input of the orthopaedic surgeon is often needed to provide the best information available to ensure that the best interests of the child and the family are protected. Working within a hospital team is the preferred method, but direct courtroom testimony is sometimes necessary.

Increased incidence of CPR-related rib fractures in infants--is it related to changes in CPR technique?

OBJECTIVE

A recent increase in the number of infants presenting at autopsy with rib fractures associated with cardio-pulmonary resuscitation (CPR) precipitated a study to determine whether such a phenomenon was related to recent revision of paediatric resuscitation guidelines.

METHODS

We conducted a review of autopsy reports from 1997 to 2008 on 571 infants who had CPR performed prior to death.

RESULTS

Analysis of the study population revealed CPR-related rib fractures in 19 infants (3.3%), 14 of whom died in the 2006-2008 period. The difference in annual frequency of CPR-related fractures between the periods before and after revision of paediatric CPR guidelines was statistically highly significant.

CONCLUSIONS

The findings indicate that CPR-associated rib fractures have become more frequent in infants since changes in CPR techniques were introduced in 2005. This has important implications for both clinicians and pathologists in their assessment of rib fractures in this patient population.

The treatment of upper limb fractures in children and adolescents

BACKGROUND

The treatment of fractures in children and adolescents must be based on an adequate knowledge of the physiology of the growing skeleton. Treatment failures usually do not result from technical deficiencies, but rather from a misunderstanding of the special considerations applying to the treatment of fractures in this age group.

METHODS

We selectively reviewed recent publications on the main types of long bone fracture occurring in the period of skeletal development.

RESULTS

Alleviating pain is the first step in fracture management, and due attention must be paid to any evidence of child abuse. The goals of treatment are to bring about healing of the fracture and to preserve the function of the wounded limb. The growth that has yet to take place over the remaining period of skeletal development also has to be considered. Predicting the growth pattern of fractured bones is a basic task of the pediatric traumatologist. During the period of skeletal development, conservative and surgical treatments are used in complementary fashion. Particular expertise is needed to deal with fractures around the elbow, especially supracondylar humeral fractures, displaced fractures of the radial condyle of the humerus, radial neck fractures, and radial head dislocations (Monteggia lesions). These problems account for a large fraction of the avoidable cases of faulty fracture healing leading to functional impairment in children and adolescents.

CONCLUSION

The main requirements for the proper treatment of fractures in children and adolescents are the immediate alleviation of pain and the provision of effective treatment (either in the hospital or on an outpatient basis) to ensure the best possible outcome, while the associated costs and effort is kept to a minimum. Further important goals are a rapid recovery of mobility and the avoidance of late complications, such as restriction of the range of motion or growth disorders of the fractured bone. To achieve these goals, the treating physician should have the necessary expertise in all of the applicable conservative and surgical treatment methods and should be able to apply them for the proper indications.