Twisting injuries create spiral fractures in long bones, highly specific for child abuse in children who are not yet ambulatory. Spiral fractures in ambulatory children lose their specificity for child abuse but remain a potential manifestation of abuse and warrant careful consideration. Whereas toddlers (1 to 3 years of age) commonly suffer spiral fractures of the lower one-third of the tibia accidentally as the result of a trivial fall or by twisting themselves on a planted foot (the so-called toddler's fracture), spiral fractures of the tibia may occur with child abuse. Spiral fractures of the femur may be accidental in toddlers but can also be seen in child abuse in this age group. Spiral femur fractures in newborns and preambulatory infants are highly suggestive of nonaccidental trauma. Correlation with the alleged mechanism of injury and a discrete but careful inspection for other evidence of abuse will prove helpful, along with a review of past injuries experienced by the child or the child's siblings.
The injury pattern most closely related to inflicted injury is that of metaphyseal-epiphyseal fractures. More specifically, chip fractures of the metaphyses or epiphyses, particularly in various stages of healing, are seen as the result of twisting or jiggling forces. Callus formation becomes striking during the healing process, along with remarkable new bone deposits along the periosteum. Subperiosteal hemorrhage may create an elevation of the periosteum away from the underlying bony cortex. Fragmentation of the clavicle and acromion and separation of the costochondral junctions of the ribs are especially suggestive of abuse.
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