“Unexplained” fractures
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2279 (Published 28 October 2008) Cite this as: BMJ 2008;337:a2279
All rapid responses
Child abuse has its own proportions as a social and medical problem.
The number of abused and neglected children in the United States rose from
1.4 million in 1986 to 2.9 million in 1993.[1] We all may agree that its
actual incidence is unknown and many cases are unreported. Unfortunately,
the problem is still identified in retrospect after a history of
repetitive trauma has been established. [2, 3]
Awareness of the skeletal signs of abuse in children is important for
physicians as well as the other injury patterns in order to diagnose and
intervene appropriately. Whereas the incidence of non-accidental fractures
decreases with increasing age, the incidence of accidental fractures
increases with increasing age up to 12 years.[4]
Civil suits have been filed against physicians for failure to report
acts of child abuse. Maliciously reporting abuse when it is not the cause
of injury, however, may expose an individual to the risk of litigation.
The caregiver's account of the injury is often vague. The degree of
physical injury may be inconsistent with the history given [5, 6, 7] and
often the reported time of injury does not correlate with the obvious age
of the injury. A delay in seeking treatment is often noted. However, a
history of repeated trauma with the child treated in several different
facilities should arouse suspicion. The parents' response to the situation
may be inappropriate. They may become overly involved. [8]
Any condition that interferes with parent-child bonding and contact
increases the risk of child abuse. Premature infants, hyperactive children
or children with disabilities are more likely to suffer abuse.[9] Because
infanticide occurs most often in the first few months of life,
intervention during pregnancy and the postpartum period is
recommended.[10] Early identification and intervention are essential.
Recognition of signs of neglect, sexual abuse, or emotional maltreatment
may lead the treating physician to consider non-accidental injury as a
possibility.
References:
1. Anonymous : Child Maltreatment 1994: Reports from State to the
National Center on Child Abuse and Neglect, Washington, DC, National
Center on Child Abuse Neglect, U.S. Government Printing Office, 1996.
2. Gross R.H., Stranger M.: Causative factors responsible for femoral
fractures in infants and young children. J Pediatr Orthop 1983; 3:341-
343.
3. Jackson G.: Child abuse syndrome: The cases we miss. BMJ 1972;
2:756-757.
4. Worlock P., Stower M.: Fracture patterns in Nottingham children. J
Pediatr Orthop 1986; 6:656-660.
5. Abuse Child : Guidelines for Intervention by Physicians and Other
Health Care Providers, Seattle, Washington State Medical Association,
1990.
6. Everything You Always Wanted To Know about Child Abuse and Neglect,
Washington, D.C., National Center on Child Abuse and Neglect, 1991.
7. Helfer R.E., Slovis T.L., Black M.: Injuries resulting when small
children fall out of bed. Pediatrics 1977; 60:535-553.
8. Green F.C.: Child abuse and neglect, a priority problem for the
private physician. Pediatr Clin North Am 1975; 22:329-339.
9. Albert M.J., Dvaric D.M.: Injuries resulting from pathologic forces:
Child abuse. In: MacEwen G., Kasser J.R., Heinrick S.D., ed. Pediatric
Fractures: A Practical Approach to Assessment and Treatment, Baltimore:
Williams & Wilkins; 1993: 388-400.
10. Overpeck M.D., Brenner R.A., Trumble A.C., et al: Risk factors for
infant homicide in the United States. N Engl J Med 1998; 339:1211-1216.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
Once upon a time, more precisely in 1946, John Caffey, published an
article "Multiple fractures in the long bones of infants sufferring from
subdural haematoma" (Am J Roentgenology; 56: 163-173). In this article he
considered fractures in the long bones as a complication of the infantile
subdural haematoma associated with the fractures of the cranium. Even
though his own illustrations (x-ray photographs) show what is generally
considered typical scurvy fractures, he denied any "roentgen signs of
scurvy". Without much ado, Caffey concluded that "The fractures appear to
be of traumatic origin but the traumatic episodes and the causal
mechanism, remain obscure". Indeed, in 1972 ("On the theory and practice
of shaking babies" Am J Dis Child; 124 (2): 161-169), Caffey proceeded to
speculate that "all of these metaphyseal avulsions appeared to result from
indirect traction, stretching, and sheering, acceleration-deceleration
stresses on the periosteum and articlular capsules, rather than direct,
impact stresses such as smashing blows on the bone itself". Then, without
a shred of evidence, he called these findings "traumatic involucra" which
commonly accompany the metaphyseal avulsions and involve the same terminal
segment of the same shaft. He thought that such injuries develop due to
traction-rupture of abundant normal perforating blood vessels, which are
severed at the junction of the internal edge of the periosteum with the
external edge of the cortex.
It is difficult to understand why such classical scurvy fractures as
shown in Caffey's own photographs were misinterpreted even in his time;
however, Caffey admitted in his 1965 article "Significance of the history
in the diagnosis of traumatic injury in children" (J Pediatrics; 67 ((5):
1008-1014) that "It is still a wonder to me that Ross Golden welcomed me,
a pediatrician without either formal of informal training or experience in
radiology, into his department of radiology and highly trained
radiologists." Why, indeed? The fact remains that Caffey made a mess of
things which even the years of supposedly professional radiology have not
rectified. The sooner the rectification begins the better for not only
thousands of victims of Caffey's (and his followers') obvious ignorance
and closed mind, but also for those formally trained radiologists who
blindly follow misinterpretations of a formally untrained Caffey.
Hiller (1972), a formally trained Australian radiologist,
demonstrated that Caffey's misunderstood bizarre fractures are in fact
caused by scurvy, even though he did not explain what actually caused
scurvy in the affected babies ("Battered or not - the reappraisal of
metaphyseal fragility". Am J Roentgenol Radiol Therapy & Nuclear
Medicine; 114 (2): 241-245).
According to Hess' far ahead of his time book (1920. Scurvy past and
present. Philadelphia and London J.B. Lippincott Company: 279pp), one of
the symptoms of scurvy are haemorrhages such as into the gums, frenulum,
skin and bones, into the stomach, intestines (with fatty infiltration of
the liver), into the eye, under the conjunctiva or into the anterior
chamber leading to the destruction of the eyeball. He described petechial
haemorrhages into the lungs, pericardium and elsewhere, meningeal
bleeding, which may give rise to apoplexy, haemorrhaging into scapula,
periosteum and jonts; infantile scurvy (which may by acute or subtle, sub-
acute or latent), with bizarre fractures of the long bones, ribs
(separation at the costo-chondral junctions resulting in beading),
scapula, cranium, separation of the epiphyses of the head of the humerus,
and partial or complete separation of the lower ends of the femur,
bleeding into muscles or between the muscle planes, joints, heart
characterised by moderately dilated ventricles, and right hypertrophy, the
heart muscle pale and tough, the cardiorespiratory syndrome, oedema etc.
etc. etc. Scurvy affects all systems of the body.
Scurvy in the twentieth and twenty first century?
These days people generally think that nobody suffers scurvy, which
used to be identified with long sea voyages during which the sailors were
deprived of any fresh fruit and vegetables. The reality is far from such
idealised perceptions. Most people probably have only marginal reserves
of vitamin C and this applies particularly to babies and small children.
Moreover, administration of vaccines depletes the marginal vitamin C
reserves very quickly and this results in an acute scurvy. Vaccines of the
kind given to babies as early as at birth (hepB vaccine) and DPT, Polio,
Hib and pneumococal vaccines at 6-8 weeks, 2 and 4 months and other
vaccines later on, contain beside adjuvants and preservatives, pertussis,
diphtheria and tetanus, measles, mumps rubella toxins which are treated
with formaldehyde to lower their virulence and toxicity. However, all of
these treated toxins (toxoids), bacteria and viruses have the ability to
revert back to their original toxicity and virulence by passage in the
injected individuals, as demonstrated by Samore and Siber (1992. Effect
of pertussis toxin on susceptibility of infant rats to Haemophilus
influenzae Type b. J Infect Dis; 165: 945-948) and as early as in the
sixties by Gerber et al. (1961. Inactivation of vacuolating virus (SV40)
by formaldehyde. Proc Soc Exp Biol & Med; 108:205-209) and Fenner
(1962. The reactivation of animal viruses. BMJ; July 212: 135-142). Two
Czech researchers, Pekarek and Rezabek, demonstrated already in 1959 (An
endocrinological test for inocuity of the pertussis vaccine. J Hyg
Epidemiol Microbiol Immunol; 3: 79-84) that when rats are injected with
pertussis vaccine, they develop an acute scurvy. My comment is that the
difference between rats and human species is in that rats produce their
own vitamin C and recover, while human babies do not produce their own
vitamin C and may not recover unless they are given large doses of vitamin
C (sodium ascorbate). By the way, vitamin C is essential for the
production of collagen which is essential for the bones and connective
tissues.
Many of those who have been involved in the study of shaken baby
syndrome (according to a California judge, it is a factitious diagnosis
carefully fabricated by medical profession) have been rather shy or silent
about the administered vaccines, even though those vaccine injections are
as a rule the only documented facts. Without revealing the vaccination
status of the affected babies, the whole issue is not going to be
resolved. In court cases when parents are accused of injuring their child,
it amounts to withholding vital information. Indeed, more recently some
judges in Australia threw out the accusations of SBS because of
insufficient evidence (of the alleged shaking or whether shaking can
actually cause the observed injuries). One can't convict a person based
on an opinion; medical opinions are subject to errors and changes. In a
normal ordinary murder case people cannot be convicted on someones'
opinion; in cases of SBS the accused parents are effectively convicted on
someone's opinion.
The picture is really crystal clear, at least for people who really
study medical literature right from the first and original articles. If
you set out to study the ancient Rome, you should read the authors who
lived in the ancient Rome and not those who did not and who, inevitably
base their perceptions of the ancient Rome on second and third hand
information. Everybody is familiar with the school children's game "The
Chinese whispers": the original word totally changes before it reaches the
last person in a line. In medicine, for some reason which escapes me, many
authors think that they not only don't have to, but they must not study
older published information. Their patients may suffer.
Moreover, due to the known inevitable political interference,
political correctness may delay the truth for centuries. Yes, I am
referring to The Holly Inquisition. However, these days we have a freedom
of speech and the truth is allowed to prevail. Why not see and reveal it?
Competing interests:
None declared
Competing interests: No competing interests
I was accused of child abuse and inflicting injuries to my youngest son back in 1986, a spiral fracture of the tibia was confirmed, after he had jumped from the side of the bath and landing awkwardly.
He was taken too the local casualty department, after having problems weight bearing and being in a lot of visible pain.
We were questioned by various medical personnel, with reference to how the fracture occurred, and was told by a paediatrician, that the leg injury was caused by non accidental injury.
There were no signs of trauma to the right leg, no bruising, swelling, or external marks of any description.
My husband and I returned home, after leaving our son on the ward for observation, after his leg had been put into plaster.
On returning to the hospital several hours later, we were informed by nursing staff that Social Services had been informed and had taken him from hospital on a Place of Safety Order, into foster care.
The evidence given to the court, with reference to the care proceedings, was from a paediatric radiologist, who was given a set of x rays and asked to make an opinion on how he thought the injury occurred. We later found out that this professional had not even seen our son.
Our son was later returned to us. Social Services and the powers to be said, that the “incident could have been accidental”, he was later found to be suffering from OI and he had the classic symptoms of brittle bone disease - shortness in stature with blue sclera to the whites of his eyes.
The false allegation has ruined my life for ever and I now despair for my Baby Granddaughter, who looks like she may have some signs of this disease, which will continue too cause conflicting medical evidence, because within the mild forms of OI, x rays of bones appear to look normal and there is still no real blood test that can confirm the bones of contention.
Competing interests:
None declared
Competing interests: No competing interests
Editor
I read the contribution from Innes with alarm and incredulity
I have however now seen that he came up with equally surprising views
regarding the death of Victoria Climbie
May I suggest that he records his competing interests as 'I believe
that the lesions noted on Victoria Climbie were due to Kawasaki disease'?
Your readers will then have further information when considering the
import of what Innes writes.
thankyou
Peter Ehrhardt
Competing interests:
I see a great many children who have been injured by their parents
Competing interests: No competing interests
Editor,
Overturning the conviction of Angela Cannings for killing two of her
children, Lord Justice Judge said that medical science was "still at the
frontiers of knowledge" about unexplained infant deaths (1).
Biochemists investigating the role of Vitamin K in the body are at
that frontier of knowledge when it comes to explaining fractures, bruises
retinal and intracerebral haemorrhages in these children.
The Medical Profession, or more specifically “designated doctors”
must abandon the mantra “THINK DIRTY” and take heed of what Dr Puntis
calls “a number of less than useful references ” if they are not to find
themselves before the GMC for false allegations of child abuse.
Before accusing a parent or care giver of murder they must heed the
advice in the “less than useful references” and exclude a deficiency of
Vitamin K by performing a PIVKA test and a test for Undercarboxylated
Osteocalcin . This will protect them from being struck off the Register.
As regards Victoria Climbie he attributes a nonsensical conclusion
to me - “because Victoria Climbie had skin lesions at the time of her
death she must have had Kawasaki’s disease.” It was not that the child had
skin lesions but the type of lesions and other clinical features which
were typical of Kawasaki disease in my experience.
However, instead of snapping at my heels, he can prove I am wrong by
persuading the authorities to release the Laboratory findings and show the
characteristic blood changes of Kawasaki Disease - Neutrophilia,
Lymphopenia, AST and ALT both increased with AST > ALT - were not
present.
Michael Innis
Reference
1 Dyer C Parents convicted of killing to have their cases reviewed
BMJ 2004;328:183 (24 January), doi:10.1136/bmj.328.7433.183
Competing interests:
As previously declared
Competing interests: No competing interests
Dr Innis provides a number of less than useful references to support
his unorthodox views on the role of nutrient deficiencies in 'unexplained'
childhood fractures. It should be clear to Dr Innis that to cite evidence
of vitamins having an affect on bone metabolism (not contentious in
itself) is poles apart from establishing causality of vitamin deficiency
in ‘shaken baby syndrome’. In fact, it’s a bit like saying that because
Victoria Climbie had skin lesions at the time of her death she must have
had Kawasaki’s disease (1). His views also seem to disregard the
possibility that even children with nutritional deficiencies can be
subject to non-accidental injury. Dr Erhardt may feel, like Dennis Healey,
no more than that he has been ‘savaged by a dead sheep’. Unfortunately the
obfuscation of science by some proponents of 'orthomolecular
medicine' such as Dr Innis could ultimately harm vulnerable children.
1. Kawasaki disease unrecognised. BMJ rapid responses, September 2007
Competing interests:
I look after children with nutritional deficiencies, and occasionally those with non-accidental injury
Competing interests: No competing interests
Editor,
Regarding “unexplained” fractures in allegedly abused children Peter
Ehrhardt wants to know “what has changed in the 21st century”.
The change is fractures can now be explained by nutritional
deficiencies of Vitamins K or C (1,2,3,4,5,6,).
The 20th century explanation of fractures in the medical aberration
called Shaken Baby or Shaken/Impact Syndrome is a thing of the past and
should be relegated to the scrap heap of history.
Michael Innis
References;
1. Koshihara Y, Hoshi K. Vitamin K2 enhances osteocalcin accumulation
in the extracellular matrix of human osteoblasts in vitrio. J Bone Miner
Res 1997;12(3):431-438
2. Latzin P, Griese M, Hermanns V, Kammer B. Sternal fracture with
fatal outcome in cystic fibrosis
Thorax 2005; 60:616
3.Vermeer C. Review Article Gamma-Carboxyglutamate-containing
proteins and the vitamin k-dependent carbpxylase.Biochem J 1990;y 266:625-
636
4. Innis MD. Vitamin K Deficiency Disease J Orthomol Med 2008;23: 15
-20
5. Weatherall, Ledingham IGG, Warrell DA. Oxford Text Book of
Medicine Second Edition Vol 1 Ch 17 page 36. Battered baby.
6.Clemetson CAB. Child Abuse or Barlow’s Disease Med Hypotheses 2002;
59(1): 52-56
Competing interests:
As previously declared
Competing interests: No competing interests
Editor
I'm disappointed in James le Fanu. He's always managed to give off
the aura of someone who is cultured and presumably well read. Now, to my
dismay, I learn that he seems not to be. I wonder what he thinks has
changed in the 21st Century? We know that, in antiquity, 'responsible'
parents beat their children: we know that 'responsible' parents beat their
children more recently, in the 18th & 19th Centuries: and we know this
from reading the writers of those eras.
We know that 'responsible' parents beat their children in the 20th
Century - we've been there, trying to pick up the pieces.
Why on earth should we imagine that 'responsible' parents have
stopped beating their children in the 21st Century?
Peter Ehrhardt
Competing interests:
1. I meet a great many children who have been beaten by their parents
2. I don't know how, when I meet a parent, I can identify whether he or she is 'responsible'.
Competing interests: No competing interests
When to suspect child maltreatment
Yesterday, the National Institute for Health & Clinical Excellence (NICE) posted draft guidelines "When to suspect child maltreatment" on it website (see
here). They are out for consultation until 10 February. The Guideline Development Group members agree that "A prospective comparative study of fractures in physical abuse, conditions leading to bone fragility and those resulting from accidental trauma to encompass a study of metaphyseal fractures specifically is needed because the existing evidence base does not fully account for differential diagnosis of fractures in the infant and toddler age group" (page 47 of the full guideline, and page 29 of the NICE guidline).
Competing interests:
None declared
Competing interests: No competing interests