Non Accidental Trauma

In Colorado as in all of the states child abuse investigations can become the nightmare of every parent. Accidental injuries such as broken bones in an infant or small child can quickly turn even the most concerned and caring parent into a suspected child abuser.

This article explores one major area of suspected child abuse bone fractures.

Doctors, nurses and social workers are under a mandate in Colorado to report suspected child abuse. If a “pre-verbal infant or child” appears in the Emergency Room with physical injuries the attending physician will automatically order a very thorough history and physical examination.

Part of that history may result in an opinion of “suspicious findings” a situation where the child’s injuries are considered medically “inconsistent with the mechanism of the injury” (how it probably occurred). That finding may be coupled with a “hanging” or a vague history surrounding the injury may be enough to launch an aggressive and unyielding investigation that can change the lives of the people in that child’s life forever.

ER physicians have the responsibility for diagnosing child abuse. The matching of history, physical examination, radiographic findings and developmental capabilities in each case may produce an accurateor an inaccurate diagnosis of child abuse or “ non-accidental trauma.”Mistakes are made often and the stakes are very high for those who have been targeted with the very direct result of those mistakes the label of “child abuser.”

In the ER a fracture in children under 1 year of age will raise the red flag of suspected abuse.

If there are multiple fractures, bilateral long bone fractures, fractures that are in different stages of healing, and fractures in children with developmental disabilities, the Colorado Child Protection Team of Children’s Hospita l will almost certainly be contacted.

Doctors will look at fractures of the humerus, femur and tibia as most likely evidence of an abused child and the younger the age of the child the more likely abuse will be seen as the “etiology” of the injury. An infant’s arms and legs are often used by abusive parents as a “handle” so the infant for the child to be thrown or shaken.

These same fractures in the very same regions described also occur ACCIDENTALLY, especially if the child is very ambulatory. The history of the child’s developmental milestones the likely mechanisms of injury, and the PATTERN of the fracture become key evidence in these cases.

Metaphyseal corner fractures are most commonly known as ‘bucket handle fractures, from the allegation that they happen as a result of a forceful shaking, or a pulling or twisting injury. It is believed that “significant force” is needed to produce this kind of fracture.

Fractures involving the hands and feet in non-ambulatory patients such as those involving fingers and toes (metatarsals and metacarpals) also raise suspicion. Non-extremity fractures such as rib, sternal and scapular fractures are seen as requiring a high degree of force not usually the result of an accident or “accidental trauma.” Rib fractures are identified most often after they have begun to heal or “calcify” (up to 14 days to become more visable).

Physicians even Child Protection Experts agree that no one specific fracture can be considered definitive for non-accidental trauma. Fractures can be caused by abuse OR by accident. If the physician suspects abuse the first of many exploratory tests a skeletal survey must be done.

Contemporary medicine requires this basic screening study be used to begin to evaluate other fractures of abuse. It is most useful for children under two years of age where there are extremity, abdominal or head traumas. The full skeletal survey is typically repeated 14 days later.

Fractures are 2nd most common presentation of physical abuse (25-50%) but child abuse as in non-accidental trauma (NAT) is found in 10% of trauma cases seen in ED in children under 3.

Fractures that are commonly seen in cases of suspected non-accidental trauma “high specificity” fractures are

• A femur fracture in a child less than 1 year old (any pattern of fracture)
• A humeral shaft fracture in a child less than 3 years old
• Sternal fractures
• Metaphyseal corner (bucket-handle) fractures (see above)
• Posterior (back) rib fractures
• Digit fractures in non-ambulatory children

If the radiological bone survey of the child’s entire skeleton the survey may confirm that the child’s injuries were not caused accidentally if the survey reveals numerous fractures in various stages of healing, the attending physicians will almost immediately diagnose non-accidental trauma (NAT).

Fractures that are in various stages of healing are found in 70% of physically abused children < 1 yr and 50% of all abused children.

• Young (age < 3 yr)
• First born children
• Unplanned children
• Premature infants
• Disabled children
• Stepchildren
• Single-parent homes

These are some of the questions physicians will address in their investigation of alleged child abuse:

• Has there been a delay in seeking medical treatment?
• Is the parent reluctant to give an explanation?
• Is the injury consistent with the explanation given?
• Does the story change between caregivers? Between child and caregiver?
• Is there substance abuse in the home?
• Are these the children of parents who were abused?
• Is the abused child overly compliant and passive or extremely aggressive?
• Is the affect inappropriate between the child and the parents? (lack of concern, overly concerned)?
• Is the family high stress such as (loss of job, etc..)?
• Evidence of drug or alcohol abuse?
• Parents in an abusive relationship?
• Has there been poor compliance with past medical treatment?
• Was The Child born to adolescent parents?
• Does the child have colic?

Here is the rub -even when there is suspected child abuse a so called “abusive etiology” the real reason for the injuries may be from genetic, nutritional, or metabolic reasons. Significant injuries may be the result of such “mechanisms” as metabolic bone disease such as rickets, nutritional deficits such as vitamin C deficiency causing scurvy, skeletal dysplasia such as osteogenesis imperfecta, infections such as osteomyelitis, and even malignancies such as leukemia.

Other sources of injuries can be vleeding disorders, photodermatitis, salicylate ingestion, Henoch-Schonlein purpura, vasculitides, and even “Mongolian spots” are commonly mistaken for non-accidental bruising.

One of the most commonly held myths of fractures attributable to child abuse si the myth of the “Spiral Fracture.” In the past spiral fractures were believed to have a high association with NAT. Today it is well accepted that spiral fractures are also commonly seen in accidental fracture patterns. A small child’s bone is the weakest in a “tension/torsion” failure mechanism and a spiral fracture can occur accidentally. Additionally toddlers also fracture their tibia (lower leg bone) commonly as a result of an accidental injury.

To demonstrate the divisions of thought in this area are always changing it is believed that femur fractures (upper leg bone from the knee to the hip) are specific to child abuse (60% to 70%) if the child is under 1 years old BUT considered accidental if the child is more than 1 years old. (60% to 70%)

One of the most reliable methods to determine whether there are bone density issues in an alleged victim of child abuse is to require bone-density tests- not just x-rays. This test should be administered in every case where unexplained fractures are to be used as evidence of child abuse. The “best evidence” of why bones have fractured are the bones themselves. A bone density test definitively establishes whether an infant with fractures actually does have low bone density and is therefore prone to bone fractures.

A bone-density scan should be performed as soon as suspect fractures are identified. If too much time passes between the incidence of the fractures and the scan, bone mineralization in the infant at the time of the bone density scan might be different than the bone mineralization at the time of the fractures. Also tests for OI and other collagen disorders should also be administered separately, since infants with OI have normal bone density in spite of the fragility of their bones.

Several years ago in a case known as the Durand case out of Rhode Island Mississippi, a four-month-old was injured. The Rhode Island court that heard Durand’s appeal upheld the conviction based on this conclusion … since there was “no fact or circumstance . . . tending in any way to support any other reasonable explanation of these injuries except that they were inflicted by its parents [since no] other person is shown to have had the custody or care of the infant save its parents.

It is precisely this kind of conclusion that requires a frontal assault on the evidence by the Defense.

Ruling out ANY accidental causes of a child’ s injuries means exhausting all possible explanations for those injuries. Bone fractures in very young infants, especially certain fractures of the clavicle, the humerus, or the femur, are well known to be caused by birth trauma. Skull fractures also often occur during difficult deliveries. Other possible congenital or acquired disorders can also account for bone fractures. For example (OI) osteogenesis imperfecta is among the most common. OI is a congenital disorder that causes severe bone fragility that almost always and can lead to fractures, even if an infant or a child is in a highly protected environment.

Other reasons for infant and child bone fractures include: accidental trauma (of course), metabolic bone disease (rickets, etc.), birth trauma and physiologic periostitis, premature birth and osteopenia of prematurity, biliary atresia, alagille syndrome, Wilson’s disease, byler disease, and hepatitis.

While all states require reporting of suspected cases of child abuse by medical professionals, Colorado actually criminally charges a professional who does NOT report suspected child abuse. If the report is made Colorado law provides legal immunity from civil or criminal liability for reporting in good faith..

What that means is that there are many more reports of suspected child abuse than almost any other crime. You need to mount an aggressive and intelligent defense to these charges should they be filed against you.

The reality of Colorado child abuse cases is that if you are convicted of child abuse you are more likely to serve a longer prison sentence than many other kinds of crimes. There is great risk in retaining a criminal defense attorney who is not experienced in child abuse investigations and prosecutions.

Juries do not like the charge of child abuse case and even though the burden of proof in these cases is the same as in every other criminal case (beyond a reasonable doubt) the jury WILL want to hear the defense case and will expect more from the defendant to prove his or her innocence than just attack the State’s case.

Any experienced and skilled Colorado criminal defense attorney knows that child abuse allegations require a proactive and aggressive approach- hire a firm that will intelligently defend you at every stage of the case from investigation through trial.

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About The Author: H. Michael Steinberg Email The Author. A Denver Colorado Child Abuse Criminal Defense Lawyer or call his office at 303-627-7777 during business hours or call his cell if you cannot wait and need his immediate assistance 720-220-2277.

If you are charged with A Colorado crime or you have questions about the topic of this article Colorado Child Abuse Investigations Non Accidental Trauma Defending Against Questionable Bone Fractures, please call our office. The Law Offices of H. Michael Steinberg, in Denver, Colorado, provide criminal defense clients with effective, efficient, intelligent and strong legal advocacy. We can educate you and help you navigate the stressful and complex legal process related to your criminal defense issue.

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