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Inflicted skeletal injury: a postmortem radiologic-histopathologic study in 31 infants
P K Kleinman1, S C Marks, J M Richmond
1Department of Radiology, University of Massachusetts Medical Center, Worcester 01655, USA.
Insights
Infants with inflicted skeletal injuries often have multiple fractures, particularly in the ribs and long bone metaphyses. Evidence of healing fractures suggests the need for thorough radiologic examination in suspected abuse cases.
Area of Science:
- Forensic Pathology
- Pediatric Radiology
- Skeletal Trauma Analysis
Background:
- Inflicted skeletal injuries in infants are a critical concern in child abuse investigations.
- Accurate identification and dating of fractures are essential for diagnosis and legal proceedings.
Purpose of the Study:
- To determine the number, distribution, and age of inflicted skeletal injuries in infants using detailed postmortem analysis.
- To compare the efficacy of skeletal surveys, specimen radiography, and histopathology in detecting these injuries.
Main Methods:
- Postmortem examination of 31 infants with confirmed inflicted skeletal injuries.
- High-detail skeletal surveys, specimen radiography, and histopathologic analysis were employed.
- Fracture dating was based on radiologic and histologic criteria, excluding skull fractures from numerical analysis.
Main Results:
- A total of 165 fractures were identified, with ribs (51%) and long bones (44%) being the most common sites.
- Metaphyseal fractures (89% of long bone fractures) were more prevalent than shaft fractures (11%).
- Specimen radiography significantly improved fracture detection rates compared to skeletal surveys alone (92% vs. 58%).
Conclusions:
- Infants experiencing inflicted trauma frequently present with fractures at multiple skeletal sites.
- The fracture patterns in infants differ from older children, with a higher incidence of metaphyseal and rib fractures.
- The presence of healing fractures underscores the importance of comprehensive radiologic assessment in both living and deceased infants suspected of abuse.
Objective:
The objective of this postmortem study was to use high-detail skeletal surveys, specimen radiography, and histopathologic analysis to determine the number, distribution, and age of inflicted skeletal injuries in infants studied at the University of Massachusetts Medical Center from 1984 to 1994.
Materials And Methods:
Thirty-one infants (average age, 3 months) who died with inflicted skeletal injuries were studied with high-detail skeletal surveys and specimen radiography and histopathologic analysis. The distribution and number of fractures was determined for each technique, and dating was performed on the basis of radiologic and histologic criteria. The skull fractures noted in 13 cases were excluded from the numerical analysis.
Results:
The radiologic-histopathologic correlation revealed 165 fractures involving the ribs in 84 (51%), long bones in 72 (44%), bones of the hands and feet in 6 (4%), clavicles in 2 (1%), and spine in 1 (< 1%). Of the 72 long bone fractures, the metaphyses were involved in 64 (89%, or 39% of the total), and the shaft was involved in 8 (11%, or 5% of the total). One hundred sixteen fractures were healing, 36 were acute, and 13 were of indeterminate age. In all but two infants, at least one healing fracture was present. Of fractures diagnosed histopathologically, specimen radiography increased the yield of fractures noted on skeletal survey from 58% to 92%.
Conclusion:
Most infants who die with inflicted injury have fractures at multiple sites. Metaphyseal and rib fractures are much more common than long bone shaft injuries, the opposite of the pattern found in older children. Because most abused infants who die have evidence of healing fractures at the time of autopsy, aggressive radiologic efforts to identify these injuries in living as well as in decreased infants appear justified.