Fractures

1. Fractures Mary Clyde Pierce MD Northwestern University Feinberg School of Medicine Emergency Medicine, Children�s Memorial Hospital Medical Director Injury Risk Assessment and Prevention Laboratory

2. Evidence 4 �Cs� the truth Consistency of history (does the story change) Compatibility of fracture with history (are the biomechanics of fracture type supported with the biodynamics of the history) Congruency of described actions and care seeking (are described actions and behaviors congurent with the pathophyisoical effects of the fracture?) Cutaneous � (any atypical bruises such as bruing to an infant or bruies to the torso, eyes, ears, cheeks, or neck present? If so buyer beware!)

3. The most common reason for physician reporting to social services is that the injury and history are not consistent. What are the guiding scientific principles supporting that determination, and what elements of that determination are objective?

4. Learning Objectives:  Apply simple biomechanics concepts to assess fracture types and clinical characteristics. 2. Be able to use biomechanical principles to determine if the history and injury are compatible. Apply concepts of an injury plausibility model for assessing fractures cases.

5. Who�s in the audience today?

6. It takes a village � Circle of abuse and re-injury

7. Fractures: why do they matter and what does the fracture tell us about the environment? Bone: what is it? Biomechanics: physical laws meet common sense Plausible?: moving from possible to plausible Cases Today�s approach

8. The skinny baby career launcher A 6 month old born early at 28 weeks Now with FTT Presents with leg swelling/not using leg Isolated, displaced transverse femur fracture Injury causation: large mom sat on baby on the bed (she thinks); or maybe it happened when the boyfriend was tossing him up in the air over the bed but missed Detached: physicality

9. Is this story possible? Is this story plausible?

10. Injury Plausibility History quality? Injury compatibility? Time congruency? Skin findings? Psychosocial findings? What and how the story is told � take the history don�t make the history: be a good listener � silence is golden Fracture morphology: understand injury biomechanics to know if it is consistent with the provided story; understanding child development � and motor capabilities is also required if the story involves the child acting Understanding how injuries evolve and clinically manifest is key � the physiology of bone injury Skin: the simplest of the required plausibility elements: until you know the head to toe, you cant know plausibility The real point: what�s the environment � what�s the investment or lack therein in the child? What and how the story is told � take the history don�t make the history: be a good listener � silence is golden Fracture morphology: understand injury biomechanics to know if it is consistent with the provided story; understanding child development � and motor capabilities is also required if the story involves the child acting Understanding how injuries evolve and clinically manifest is key � the physiology of bone injury Skin: the simplest of the required plausibility elements: until you know the head to toe, you cant know plausibility The real point: what�s the environment � what�s the investment or lack therein in the child?

11. Fracture morphology Which bone? Where on the bone? Fracture type? Displacement? Acute or healing?

12. Why do fractures matter?

13. Is physical child abuse preventable?

14. Is physical child abuse curable?

15. Traumas are preventable Illnesses are curable Child physical abuse is both the result of a traumatic event and a "psychosocial illness� Therefore child physical abuse is preventable and curable

16. Child physical abuse is not an adult physical action problem It is the physical manifestation of an adult psychosocial problem

17. It is the physical manifestation of the adult�s �mental healthiness� problem This is why child abuse has such lethality

18. Empathy on furlough Expectations are off When the infant or child fails to meet the expectation, interpreted as defiant, on purpose Teach them a lesson/ whose boss/ not in my house/ physical means to �correct� Got what they deserved, if they had not been�.then I would not have to �correct� him�.. Other empathy snatchers: exhaustion, fatigue, stress, isolation

19. Cure: address the psychosocial �dyshealth or ailment� Physical abuse is not a problem with physical action so focusing on correction of physical action will fall short of a cure. The problems are multifactorial: social and psychological The cure, specific for each child, is possible by addressing the psychosocial issues for each child�s family situation. Cures range from simple treatments to intense therapies to �transplants.� Abuse is an escalating form of trauma - these �family illnesses� will get worse without the proper interventions

20. Fractures are second only to bruising as a presentation of child abuse Indicate the child is being subjected to extreme and potentially life-threatening violence In 50% of cases, the fracture is the only finding

21. Study Outcomes in children with fractures resulting from unrecognized abuse

22. 144 children hospitalized with injuries from child abuse (CHP) 71 children with fractures 28% had healing fractures 8 cases: fracture identified but abuse missed / risk underestimated 4 died 2 sustained severe brain injury All from subsequent abusive trauma

23. The most common long bone fractures caused by child abuse? Femur and humerus 1/3 of femur fractures in children under 4 yrs are caused by child abuse 50% of humerus fx in a children under 3 yrs are caused by child abuse Fracture facts

24. Consider: child�s age and level of development 80% of child abuse fractures occur in children less than 18 months of age 25-50% of fractures in children under 1 yr of age are caused by abuse 80% of long bone fractures in children under 1 year of age are caused by abuse After the child begins to walk, the % of fractures caused by abuse declines abruptly 1/3 of femur fractures in children under 4 yrs are caused by child abuse

25. Specificity for abuse High specificity Moderate and Low specificity Rib fractures Posterior: PPV 95% Classic metaphyseal fxs Most common long bone fx in children who die from abuse Scapular fx Spinous process fx Sternal fx Complex skull fx Epiphyseal fx Vertebral body fx Digital fx Long bone fx Linear skull fx Clavicle fx SPNBF

26. What�s the big deal about fractures?

27. be immediately obvious with swelling, or occult and difficult to identify, take a day or 2 to produce painful symptoms, or immediately cause incapacitating pain, be very easy to see on xray, or take a few weeks to show up, cause immediate inability to walk, or only show up as a mild limp, So what�s the confusion????? Fractures can:

28. The skinny baby A 6 month old former premie with FTT Injury causation: large mom sat on baby on the bed the night before (she thinks) Isolated transverse femur fracture

29. How much force did it take to cause this fracture? Why is this question so difficult to answer? Developing bone changes daily Multiple components to the structure Tissue is anisotropic and viscoelastic Prematurity and nutritional status affects bone quality

30. Bone: what is it and how does it work?

31. Biomechanics

32. Likelihood of Fracture Dependent upon: Extrinsic factors (external) the specifics of the event (e.g. fall) loading conditions, direction and rate Intrinsic factors (internal) factors inherent to the bone�s structure, composition and material properties geometry, bone mineralization

33. Likelihood of a building falling� Whether or not the building falls depends on 3 key factors: the amount of energy available (summer breeze vs Katrina) the direction of the force relative to the structure (west vs east side) �anistotropic� the ability of the structure to respond to the load (what�s the building made to withstand�3rd world devastation vs developed world) These same factors also determine the specific failure characteristics or morphology: (shape/type/degree)

34. Fracture occurrence Whether or not the bone fails depends on 3 key factors: the amount of energy available, the direction of the force, the ability of the tissue to respond to the load These same factors also determine the specific fracture characteristics (shape/type/degree) also known as fracture morphology

35. Bone: What bone broke Where on that bone is the break Does the bone appear normal Fracture characteristics The overall type of fracture tells the predominate type of load � which can be tied back to the history Buckle, transverse, spiral, oblique, cml; comminuted? Is there separation of the fracture line? - energy Partial (hairline; greenstick) Complete through and through? Is there angulation or displacement of the fragments? Are there multiple fragments (comminuted) What is fracture morphology?

36. Concepts The biomechanical properties of bone dictate that a particular level of load and a particular mechanism of loading are necessary to cause a particular type of bone fx� Accidental Injury 2002 The fx morphology is a direct reflection of the degree and direction of the forces and the ability of the tissue to resist those forces

37. Compression - stress created by �trash compacter� Tension - stress created by extending or �pulling� Shear - stress produced when force application is aligned with the surface of an object: weakest Bending - stress created when a force is applied perpendicular to the long axis of an object causing tension on one side and compression on the other � bent in half Torsion - stress resulting from twisting Direction of loading:where history meets x-ray Energy-forceEnergy-force

38. Biomechanical Terms and Concepts