As with bruises, it is possible for a child to injure him or herself, but these injuries generally take a certain form, and are usually age appropriate. Thus, a child who cannot walk is unlikely to be able to fracture a leg. The other mode of presentation is as an undiagnosed event - ie a child who is in pain for some reason apparently unclear to the parent.
Possible presenting features include:
- pain in a limb, with the infant or child reluctant to move that limb
- a number of fractures, particularly at different ages - ie in different stages of healing
- spiral fractures from twisting
- rib fractures from crushing; they tend to be posterior
- epiphyseal fractures from pulling
NICE have produced guidance as to fractures where child maltreatment should be considered:
- suspect child maltreatment if a child has one or more fractures in the absence of a medical condition that predisposes to fragile bones (for example, osteogenesis imperfecta, osteopenia of prematurity) or if the explanation is absent or unsuitable. Presentations include:
- fractures of different ages
- X-ray evidence of occult fractures (fractures identified on X-rays that were not clinically evident). For example, rib fractures in infants
Notes:
- for the purposes of this guideline, to suspect child maltreatment means a serious level of concern about the possibility of child maltreatment but is not proof of it
- a bucket-handle fracture describes the radiological appearance of a type of metaphyseal fracture associated with non accidental injury
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