RCH Clinical Practice Guideline Paediatric Fractures

VFPMS Guideline: Forensic investigation of fractures

A fracture is a complete or incomplete break in the continuity of a bone.

Children’s bones fracture more easily than adults’ bones. Fractures are common injuries sustained accidentally by active children.

Fractures are also commonly detected in abused infants and young children. 

Physical examination alone can fail to detect fractures in pre-verbal and relatively immobile infants. This means that radiological investigations might be the only way to detect occult (hidden) fractures in this age group.

Key points:

• Many children with fractures have minimal or no external sign of injury. This means that the skin over fracture sites can appear entirely normal.
• In childhood, most fractures are caused by accidental falls and collisions.
• In infants, particularly pre-mobile infants, fractures are more commonly attributed to abuse than to accidents.
• No specific fracture location or type is pathognomonic for abuse.
• Some fracture locations and types of fracture (for example, classic metaphyseal lesion patterned fractures at the ends of long bones and posteromedial rib fractures) are more commonly attributed to inflicted trauma than to accidents.
• Fractures at different stages of healing suggests that trauma occurred on different dates.
• Inflicted trauma (child abuse) can result in multiple fractures affecting multiple bones and/or fractures that appear to be at different stages of healing
• Dating of fractures is inexact. Only an estimate can be made of the window of time in which bone injury might have occurred. 

Clinical Advice:

The following information should be obtained about the presenting symptoms and signs. Ask about.

• Timing and detailed information about mechanism of injury (for example, information about impacting surface and objects, position of child when first observed after traumatic event)
• Circumstances surrounding the injury (Who was present? Who heard or saw what? What was happening prior to the event and what happened in the minutes to hours after?)
• Symptoms and signs of injury. Ask about deformity, signs suggesting pain, alteration to limb function, swelling and other signs of skin and soft tissue injury

The following information should be obtained about the past medical history. Ask about.

• Medical conditions and treatment (particularly endocrine disorders, renal and liver disease)
• Accidents (particularly past fractures and dislocations)
• Medication
• Developmental milestones and current developmental skills
  
  

The following information should be obtained about the family history. Ask about.

• Consanguinity
• Inherited bone and connective tissue diseases / genetic conditions
• 3 generation genogram regarding fractures and dislocations
  
  

The following information should be obtained about the social history. Ask about.

• Prior engagement with Child Protection and/or police. Protective and Family Violence orders
• Child-care arrangements (and recent child carers’ contacts with the child)
• Violence in the home (safety) and disciplinary practices
• Parental alcohol and drug use (past and recent)
• Parental mental illness and treatment
• Parenting experience, skills and capacity 
  
  

Examination tips

• Standing back, observe patient for possible bone deformity
• Thoroughly examine and palpate the scalp, torso and limbs. Search for signs of swelling and tenderness (a subjective sign)
• Observe gait. Observe the movement, function and voluntary use of limbs

Investigations are unlikely to be required when

• The accident/ traumatic event involving an older child has been witnessed by multiple observers (for example a child’s fall on an outstretched hand while at school) and there are no concerns about child abuse.
• There is a low probability of child abuse (determination based on the totality of clinical findings).
• The age of the child and the fracture location and type are strongly associated with accidental causes and not associated with inflicted causes (for example, Colles fracture of the distal radius, toddler fracture of the distal tibia, fracture of the clavicle in an independently ambulant child)

Consider investigations when

• A fracture is identified in a very young infant and birth trauma can be confidently excluded

• A fracture (particularly an occult fracture) is identified in a pre-mobile (not yet crawling or cruising) infant

• A fracture that has a strong association with an inflicted mechanism is identified

• A fracture is identified for which there is no apparent explanation

Investigations

Blood tests and referral to specialists

Radiological investigations

The VFPMS supports the RANZCR October 2022 guideline for imaging of suspected non-accidental injury[AS1] .

• In young children (<2years-old) with a known fracture, consider investigations to search for additional but occult fractures.

• In the presence of fractures suggesting the application of significant force to the torso, consider screening for abdominal injury.

• In selected cases (including a young infant with a fracture) consider screening tests for possible head injury.

Radiological Investigations for occult fractures:

1. When bruising prompts investigations for occult fractures

The VFPMS supports the RANZCR October 2022 guideline for imaging of suspected non-accidental injury 

The VFPMS supports the Wood et al (2014) recommendations regarding radiological investigations for occult fracture, as presented in the following table. These recommendations were developed by a panel of US child abuse experts’ consensus using a Delphi process.

_{Wood JN et al. (2015) Development of Hospital-Based Guidelines for Skeletal Survey in Young Children With Bruises. Pediatrics. 135(2);e312-20.} 

2. When known fracture prompts investigations for additional occult fractures

The VFPMS supports the RANZCR October 2022 guideline for imaging of suspected non-accidental injury. 

The VFPMS supports the Wood et al (2014) recommendations regarding radiological investigations for occult fracture, given a fracture has been identified, as presented in the following table. These recommendations were developed by a US panel of experts using a Delphi methodology when only a single skeletal survey was the most commonly used radiological investigation for occult bone injury. The RANZCR guideline is preferred over the Wood recommendations when advice is in conflict.

_{Wood JN et al. (2014) Development Hospital-Based Guidelines for Skeletal Survey in Young Children With Fractures. Pediatrics. 134(1);45-53.}

Age of child

As discussed in the tables above, radiological investigations for occult fractures are more often recommended in children under the age of 2years.

When there is a strong suspicion of occult fracture in older children (generally up to 5years of age) then consideration may be given to performing a skeletal survey.

Useful resources and articles:

• Guideline for Imaging of Suspected Non-Accidental Injury. Approved October 2022. The Royal Australian and New Zealand College of Radiologists. The Faculty of Clinical Radiology. Available at https://www.ranzcr.com/component/edocman/guideline-for-imaging-of-suspected-non-accidental-injury/viewdocument/1831?Itemid=424
• The Royal College of Paediatrics and Child Health’s review (UK, 2017) Child Protection Evidence - Fractures 
• The Canadian Paediatric Society’s Practice Point (Canada, 2018) The medical assessment of fractures in suspected child maltreatment: Infants and young children with skeletal injury 
• The American Academy of Pediatrics’ Clinical Report (USA, 2014) Evaluating Children With Fractures for Child Physical Abuse
• Wood et al. (2014) Development of Hospital-Based Guidelines for Skeletal Survey in Young Children With Fractures
• Wood et al. (2015) Development of Hospital-Based Guidelines for Skeletal Survey in Young Children With Bruises