Child abuse is a pervasive social and medical problem that remains a major cause of disability and death among children. Increased awareness has led to a better understanding of the social, medical, and epidemiologic aspects of this complex issue. Because fractures are the second most common presentation of physical abuse after skin lesions1 and because approximately one third of abused children are eventually seen by an orthopaedic surgeon,2 an understanding of the differences in the general and musculoskeletal manifestations of accidental and nonaccidental injuries is essential for recognition and appropriate management.
Both federal and state legislation provide definitions of child abuse. Federal law identifies a minimum set of acts that characterize maltreatment. Each state is responsible for providing definitions of child abuse and neglect within the civil and criminal context. Civil statutes describe the conditions that obligate mandated reporters to identify known or suspected cases of abuse, and they provide definitions necessary for juvenile or family courts to take custody of an allegedly maltreated child. Criminal statutes specify the forms of maltreatment that are criminally punishable.
The Child Abuse Prevention and Treatment Act, as amended and reauthorized in October 1996 (Public Law 104-235, Section 111; 42 U.S.C. 5106g), defines child abuse and neglect as “at a minimum, any act or failure to act resulting in imminent risk of serious harm, death, serious physical or emotional harm, sexual abuse, or exploitation of a child by a parent or caretaker who is responsible for the child's welfare.”
There are four major types of child maltreatment: physical abuse, neglect, sexual abuse, and emotional abuse. Although any of the forms of child maltreatment may be found separately, they often occur in combination. Orthopaedists are most likely to encounter physical abuse, which is the infliction of physical injury as a result of punching, beating, kicking, biting, burning, shaking, throwing, or otherwise harming a child with or without intention.
Inconsistencies in reporting and variations in definitions make it difficult to precisely determine the prevalence of child abuse and to track trends. In 1995, child protective services agencies in 49 states investigated 2 million reports alleging the maltreatment of almost 3 million children and determined that more than 1 million children were victims of substantiated child abuse or neglect. The annual incidence of child maltreatment was estimated at about 15 cases per 1,000 children younger than 18 in the general population.3 A 1993 study by the National Center on Child Abuse and Neglect involving over 5,600 community professionals estimated that 42 children per 1,000 were the victims of abuse or neglect.4
The number of abused or neglected children appears to be increasing. Three national incidence studies (conducted in 1980, 1986, and 1993) surveyed community health-care professionals and socialservice providers. The estimated number of children who experienced harm from abuse or neglect increased from 625,100 in 1980 to 931,000 in 1986 to 1,553,800 in 1993.4
Neglect is the most common form of maltreatment (52% of victims in 1995), followed by physical abuse (25%), sexual abuse (13%), emotional maltreatment (5%), medical neglect (3%), and other forms of maltreatment (2%).3
Maltreatment affects children of all ages and both sexes. Among children confirmed as victims of child abuse and neglect by child protective services agencies in 1995, more than half were less than 7 years of age, and 26% were younger than 4 years old. In 1995, 52% of victims were female, and 48% were male. Children of all socioeconomic strata suffer maltreatment, but family income appears to be related to incidence rates. Children from families with annual incomes of less than $15,000 per year were more than 25 times more likely than children from families with annual incomes above $30,000 to have been harmed or endangered by abuse.4 Demographic analysis has shown that those most at risk for maltreatment include first-born children, unplanned children, premature infants, stepchildren, and handicapped children. In addition, children of single-parent homes, drugabusing parents, parents who were themselves abused, unemployed parents, and families of lower socioeconomic status were shown to be at increased risk.2,5–7
The majority of maltreated children are abused by birth parents. Fewer are maltreated by nonbirth parents or parent-substitutes, such as a stepparent, foster parent, adoptive parent, or parent's separated or divorced spouse or current boyfriend or girlfriend. Of all abuse cases substantiated by child protective services agencies, 50% to 80% involved some degree of substance abuse by the child's parents.4,8 More than half of all reports alleging maltreatment come from professionals, including educators, law enforcement and justice officials, medical and mental health professionals, social-service professionals, and child-care providers. About 19% of reports come from relatives of the child or from the child. Reports from professionals are more likely to be substantiated than reports from nonprofessional sources.3
The exact incidence of death due to child maltreatment is unknown due to difficulties with identification and documentation. In 1995, 1,215 children were reported to have died as a result of maltreatment. Forty-six percent of these children had had prior or current contact with local child protective services agencies. Eighty-five percent of these children were under the age of 5 years, and almost half (45%) were under the age of 1 year.9 Abuse is second only to sudden infant death syndrome as a cause of mortality in infants between 1 and 6 months of age and is second to accidental injury in children over 1 year of age.7,10
Violence toward children appears to be a timeless phenomenon. Writings from the first and second centuries A.D. describe afflictions of children who may have been stricken intentionally.11 A pivotal paper was written in 1860 by Ambrois Tardieu, a French professor of legal medicine, who vividly described diagnostic injuries, parental collusion, and response to removal from an abusive environment in a series of abused children.11 The English Society for the Prevention of Cruelty to Children was first established in Liverpool in 1883.
The first half of the 20th century witnessed a growing awareness of abuse. In 1944, neurosurgeons Ingraham and Matson suggested a traumatic origin for subdural hematomas in infants, rather than the more commonly recognized infectious etiology.11 Skull fractures, retinal hemorrhages, and the generally poor condition and low socioeconomic background of the affected children were noted. In 1946, John Caffey highlighted the association between multiple fractures and subdural hematoma in a series of six infants. His classic papers contain the description of metaphyseal fragmentation, external cortical thickening, fractures in otherwise healthy bones, and fractures in multiple stages of healing. He clearly considered the injuries to be traumatic in origin even though a history of trauma was obscure.
In the 1950s, further association between nonaccidental injury and injuries in young children was suggested. However, medicine as a profession did not fully recognize the reality of child abuse as a distinct clinical entity until the landmark paper in 1962 by Kempe et al in the Journal of the American Medical Association.6 Kempe coined the term “battered child syndrome” and defined a clinical condition in which young children receive serious physical abuse from a parent. He described a clinical profile of a young child with poor hygiene, failure to thrive, soft-tissue and bone injuries, and subdural hematoma. He pointed out the discrepancy between the injuries and the given history and noted that no new lesions appeared while the child was away from the abusive environment. That groundbreaking article was essential in attracting attention to this still neglected medical and social issue.
Within a few years after publication of that article, all states mandated reporting of suspected cases by medical professionals. Increasing public awareness and outcry resulted in the passage of the Child Abuse Prevention and Treatment Act and the establishment of the National Center on Child Abuse and Neglect in the 1970s. Strides have been made regarding the epidemiology, diagnosis, management, and societal impact of child abuse and neglect. However, the syndrome remains a major cause of death and physical and psychological disability among children.
Manifestations of abuse involve the entire child. A thorough history and a complete general and orthopaedic examination are essential (Table 1). The diagnosis of child abuse is seldom easy to make and involves a careful consideration of sociobehavioral factors and clinical findings. Ideally, a team of pediatricians, social workers, and subspecialists are involved in establishing the diagnosis; however, in many situations, the orthopaedist may be alone in the recognition and documentation of physical abuse. It has been estimated that 10% of cases of trauma seen in emergency departments in children under 3 years old are nonaccidental.2 Although a number of risk factors for child maltreatment have been identified, it must be emphasized that children of all socioeconomic statuses, backgrounds, and ages can be subjected to abuse.
Abused children may be either overly passive or overly aggressive. They may have developmental delays, be characterized as irritable or hyperactive, or demonstrate destructive behavior. With children who are old enough to effectively communicate, care must be taken to ask age-appropriate questions and avoid leading questions. The stated history in cases of abuse is often vague and lacking in detail. There may have been a delay in seeking care. The parents may exhibit hostility or casualness to questioning. Often, they are hesitant to provide information, or they offer contradictory information. The given mechanism of injury is often insufficient to explain the physical findings, or the care-giver may deny any history of injury. Frequently, a fall is allegedly the mechanism of injury; however, it is unusual for a young child to sustain life-threatening injury from a fall alone.12
Skin lesions, including bruises, lacerations, scars, welts, and burns, are the most common presentation of physical abuse and may be the only physical finding. Burns are present in 10% to 25% of physically abused children, and 50% to 92% demonstrate bruising.1 Bruising of certain locations, such as the buttocks, perineum, genitalia, trunk, back of head, and back of legs, suggests nonaccidental injury. The shape of the bruises and the pattern of the burns may reflect the instrument used. Multiple bruises are more common in older children and may be in various stages of healing.1 The age of bruises and contusions can be grossly estimated by a change in color over a period of 2 to 4 weeks, with fading beginning at the periphery. The acute lesion is often blue or reddish purple; this coloration gradually changes to green and then to yellow before resolution as a brownish stain. The orthopaedist should carefully examine the patient for skin lesions before placing a cast, especially a spica cast, and should document any lesions in the medical record.
Head trauma is the most frequent cause of morbidity and mortality in abused children. Head injuries may result from direct blows, dropping, shaking, or throwing. Multiple skull fractures, bilateral fractures, skull-base fractures, fractures crossing suture lines (Fig. 1), and depressed fractures occur more frequently in abuse than in accidental injury.13 The infant brain is particularly vulnerable to acceleration-deceleration injuries. Subdural hematomas and retinal hemorrhages may be present without skull fractures in the shaken baby. Physical abuse should be suspected in any child with unexplained altered mental status, subdural hematoma, retinal hemorrhage, or skull fractures. Long-term sequelae of neurologic injuries from child abuse include cognitive disabilities, developmental delays, seizure disorders, and motor disabilities.
Visceral injuries are uncommon in child abuse, but are associated with mortality rates of 40% to 50% when they do occur.14 Most internal injuries are caused by direct blows from punching or kicking. Children may present with nausea, vomiting, abdominal distention, peritonitis, obstruction, and/or abdominal bruising. Injuries may include liver and spleen laceration, pancreatic rupture, intramural bowel hematoma, retroperitoneal hemorrhage, kidney contusion, bowel perforation, and bladder rupture. Mortality associated with visceral injuries is often the result of massive blood loss due to organ or mesenteric laceration. The high death rate associated with these injuries results not only from the severity of the injuries but also from the frequent delay in seeking medical attention.
Fractures are the second most common presentation of physical abuse, after soft-tissue bruising and burns.1 Approximately one third of physically abused children will require orthopaedic treatment.2 The incidence of fractures in child abuse ranges from 9% to 55%, depending on the type of abuse and the methods of detecting fractures.1,15
Fractures from abuse are more common in younger children, who are at greater risk because of the diminished structural and mechanical properties of the developing skeleton and because they are demanding, defenseless, and nonverbal. Long-bone fractures in preambulatory infants in the absence of metabolic bone disease are more often inflicted than accidental. Fractures resulting from accidental injury and motor vehiclepedestrian accidents are more likely after the transition to ambulation. In several studies of fractures in abused children, 50% to 69% of all fractures occurred in children less than 1 year of age, and 78% to 85% occurred in children less than 3 years of age.15–18 In reviews of the data on fractures in infants less than 1 year of age, researchers have found 45% to 56% to be associated with child abuse; of children less than 3 years old with fractures, 43% were abused.7,18–20
Multiple fractures in various stages of healing are found in more than 70% of abused children less than 1 year of age and more than 50% of all abused children.8 Nevertheless, many abused children present with only one fracture. In a series of 429 fractures in 189 battered children, King et al15 found that 50% of the children had only a single fracture, 33% had two or three fractures, and 17% had more than three fractures. Similarly, Loder and Bookout21 found that 65% of abused children had only a single fracture. Furthermore, the acute, single-diaphysis long-bone fracture that is common in accidental injury is also common in abuse. Therefore, to facilitate differentiation of accidental injuries from injuries due to abuse, rough guidelines have been established for estimating the age of fractures in children (Table 2).
In some series reporting patterns of fractures in abused children, the humerus was the most commonly fractured bone15; in others, the tibia or the femur was more common.22 In infants and young children, the presence of a femur fracture is very suggestive of abuse (Fig. 2). In reviews of the data on children with femur fractures, 30% to 46% of fractures in children less than 5 years old were due to abuse,23–25 as were 60% to 65% of fractures in children less than 1 year old.25,26
Previously, the midshaft spiral fracture had been thought to be characteristic of a violent twisting injury common in abuse. However, transverse fractures are also frequently seen in child abuse, accounting for 48% to 71% of long-bone fractures in several large series.15,16 In a review of 80 femur fractures in children less than 4 years old, Beals and Tufts22 found no difference in diaphyseal fracture pattern between fractures due to abuse and those resulting from accidental injury. Thus, no specific diaphyseal fracture pattern should be considered pathognomonic of child abuse.
Rib fractures are common in physical abuse and can result from anteroposterior (AP) or lateral compressive forces associated with squeezing, direct impact from striking, or oscillation and compression during violent shaking. Rib fractures from accidental injury are a marker of severe trauma in children due to the relative compliance of the rib cage and are often associated with a high risk of mortality.26 Even after vigorous cardiopulmonary resuscitation, rib fractures are uncommon in children. Rib fractures have been reported in 5% to 27% of abused children.27 Akbarnia et al17 found rib fractures to be almost twice as prevalent in cases of abuse as fractures of any one long bone. Kleinman et al28 performed postmortem radiologic and histopathologic studies on 31 abused infants and found that 51% of all fractures involved the ribs and that only 36% of the rib fractures were visible on skeletal survey. Almost 90% of abuse-related rib fractures are seen in infants less than 2 years of age, a reversal of the age distribution for accidental thoracic injuries.27
Rib fractures may be difficult to detect on initial chest x-ray films; they may become radiographically apparent only later due to healing callus or may not be appreciated unless radionuclide scanning is performed. Posterior and posterolateral rib fractures are most common and are highly specific for abuse (Table 3). These fractures re- sult from mechanical stress at the points of firm rib fixation adjacent to the costovertebral junction. However, fracture may occur anywhere along the arc of the rib, including the rib head and the costochondral junction (Fig. 3).
The clavicle is one of the most commonly fractured bones in accidental childhood injury; however, clavicular fractures are relatively unusual in child abuse, detected in only 2% to 7% of abused children.17,27 Similarly, fractures of the hands and feet are common in accidental injury but fairly uncommon in abuse.
True physeal fractures are uncommon in the abused child, except for transphyseal fractures of the distal humerus in children less than 1 year old. Physeal separations are most often the result of violent traction or rotation, as opposed to shaking, and may be complicated by growth disturbance. The injury is evidenced radiographically by abundant healing callus (Fig. 4); however, early diagnosis may be difficult before the appearance of the epiphyseal ossific nucleus, necessitating the use of other imaging modalities, such as arthrography, sonography, and magnetic resonance imaging.
Metaphyseal injuries are less common than diaphyseal fractures, with an incidence in cases of child abuse varying between 5% and 44%, depending on the screening method used.8,15,16,21 However, metaphyseal lesions have high specificity and are considered to be a “classic” radiographic finding in physical abuse (Fig. 5). On the basis of extensive radiologic and histopathologic postmortem examination of abused children, Kleinman et al29 concluded that metaphyseal injuries are a consequence of planar fractures through the primary spongiosa, which result in a disklike fragment of bone and calcified cartilage (Fig. 6). This may appear as a transverse radiolucency within the subphyseal region of the metaphysis. On an oblique projection, this fragment has a buckethandle appearance. If the periphery of the fragment is thicker than the center, the lesion appears as a characteristic corner fracture.
Periosteal avulsion and subperiosteal hemorrhage in the metaphyseal region result in new-bone formation 5 to 14 days after injury. Repetitive injury may result in widening of the radiolucent metaphyseal zone with cupping. The forces necessary to produce these lesions involve rapid accelerationdeceleration or torsion-traction and thus are suggestive of violent shaking or twisting. Metaphyseal impaction injuries may result in periosteal new-bone and buckle fractures.
The incidence of spinal injuries from abuse has ranged from only 0% to 3% in large series.22,30 Most spinal injuries in child abuse are asymptomatic compression fractures detected on skeletal survey in younger children (Fig. 7). Abused children rarely demonstrate significant kyphosis or neurologic abnormality from spinal injuries. Disk-space narrowing and anterior vertebral notching may be noted. Fracture or avulsion of the spinous processes is fairly specific to abuse (Table 3). Most injuries occur in the lower thoracic and upper lumbar spine, and multiple levels may be involved. The mechanism of injury is often the hyperflexion and hyperextension associated with violent shaking.
While there is no pathognomonic fracture pattern, there are a number of general patterns that may help differentiate accidental from abuse fractures. Worlock et al30 compared fractures in 35 abused children with fractures in 826 nonabused children. The abused children were younger, with 80% less than 18 months of age; all were less than 5 years of age. Only 2% of children with accidental fractures were less than 18 months old, and 86% were older than 5 years of age. In addition, abused children were more likely to have multiple fractures, bruising of the head and neck, rib fractures, and spiral humeral-shaft fractures.
Comparing the findings in 52 children under 3 years of age with fractures from abuse and 145 children with accidental injuries, Leventhal et al18 found that abused children were more likely to sustain a midshaft or metaphyseal humerus fracture, to sustain a tibia or femur fracture if less than 1 year of age, and to have a care-giver who reported no accident but merely a change in behavior. Injuries more common with accidental injury included clavicle fractures, fractures of the distal extremities in children older than 1 year of age, supracondylar humerus fractures, and femur fractures in children over 1 year of age who had fallen while running.
In a study of 49 infants less than 12 months old with fractures, Rosenberg and Bottenfield7 found that fractures of the humerus or femur with an unknown mechanism of injury were more common in cases of abuse, and clavicle fractures were more common in accidental trauma. However, these differences in injury patterns between abuse and accidental injury must be viewed in the light of studies in which no statistically significant differences were found in the incidence of long-bone fractures or in fracture pattern.19,20,31
In addition to imaging of acute injuries, a skeletal survey is often used to detect the presence of additional fractures in physically abused children (Table 4). Multiple images are preferable to a single AP x-ray film of the entire infant, because of the obliquity and lack of detail often seen with this “babygram.” Skeletal surveys are more useful in children less than 5 years of age who have clinical evidence of physical abuse. The American Academy of Pediatrics Section on Radiology has recommended a mandatory survey in all cases of suspected abuse in children younger than 2 years of age and individualized use of a survey in children aged 2 to 5 years based on clinical indicators.32 In children over the age of 5 years, a skeletal survey was considered to have only minimal value.32 Fractures detected incidentally on skeletal survey are rarely present without clinical evidence of physical abuse by history or physical examination.27 The yield of skeletal surveys in cases of neglect and sexual abuse is low. The yield of skeletal surveys in children over 3 years of age is also low because occult asymptomatic bone injuries are rare.
The use of radionuclide bone scanning as a screening procedure in physical abuse is controversial. Bone scans are more sensitive than skeletal surveys in screening for physical abuse, especially in detecting rib fractures, nondisplaced long-bone fractures, and occult bone injuries (Fig. 8).33 However, disadvantages of bone scanning include cost, radionuclide exposure, lack of specificity, and limited availability and expertise. In addition, it may be difficult to detect epiphyseal-metaphyseal abnormalities (because of the normally increased activity in this region) and to date fractures. Thus, many recommend radionuclide bone scanning when skeletal surveys are negative or questionable despite a clinical suspicion of abuse.27 Repeating a skeletal survey 2 to 3 weeks after the initial presentation can assist in the identification, confirmation, and dating of questionable fractures.
The differential diagnosis of child abuse includes other conditions that can lead to fracture, periosteal elevation, or bruising in young children. The differentiation between mild forms of osteogenesis imperfecta (OI) and child abuse can be particularly vexing and deserves special mention.
Because OI is rare and nonaccidental injury is common, the possibility of OI may be overlooked when the child seems clearly to have suffered a nonaccidental injury. There have been sporadic high-profile cases in which children identified as victims of abuse were later found to have mild forms of OI. Undiagnosed OI should be considered when a child presents with multiple fractures but a history of minimal trauma. Characteristics of OI that may be useful in differentiation from child abuse include blue sclerae, dental involvement, osteopenia, family history, wormian bones on skull radiographs, and deformity (Fig. 9). However, patients with milder forms of OI, such as Sillence type IV, may have normal sclerae, no dental involvement, minimal osteopenia, and, due to spontaneous mutations, no family history of OI. In addition, blue sclerae can be normal in infants up to the age of 4 months.
To make the differentiation even more difficult, it must be considered that children with OI may also be the victims of abuse. In OI as in abuse, the purported mechanism of injury often seems insufficient for the resultant fracture. However, in otherwise normal bones and in the absence of features associated with OI, unexplained fractures are much more likely to represent abuse than a rare mild form of OI.34 Metaphyseal corner fractures, rib fractures, subdural hematoma, retinal hemorrhages, and skull fractures are not typical features of OI. Resolution of fracturing in a protected environment also supports abuse. Although the diagnosis of OI is still based primarily on clinical and radiographic criteria, fibroblast cell culture from a skin biopsy specimen can now be used to detect molecular abnormalities of type I collagen in approximately 85% of OI cases.
Osteogenesis imperfecta is but one example of the complexity of accurately diagnosing child abuse. It is essential that the physician be aware of all the possibilities that must be considered in the differential diagnosis of that protean entity (Table 5).
The first and most vital step in the management of child abuse is to establish the diagnosis. A tactful and tempered approach should be taken at the initial encounter, as many cases of suspected abuse are found to be unsubstantiated. Nevertheless, although false suspicion of child abuse can be stigmatizing and burdensome to the family, the consequences of failure to diagnose can be fatal. It has been estimated that failure to diagnose an initial presentation of child abuse may result in a 30% to 50% chance of repeated abuse and a 5% to 10% chance of death.2,10 With reinjury, parents often seek care at a different medical facility. Physicians and other health-care providers are required by law in most states to report suspected cases of child abuse, and failure to report has increasingly resulted in sanctions, fines, exposure to liability, and claims of malpractice. A reporter does not have to be certain that abuse or neglect has occurred; he or she must simply have a reasonable suspicion of maltreatment. The law affords the reporter immunity from civil or criminal liability stemming from the act of reporting, such as a charge of defamation or invasion of privacy (however, malicious reporting may expose the reporter to litigation).
The management of a physically abused child ideally involves a team approach. Most hospitals that treat a substantial number of children have such a team. When in an adult hospital or a community hospital without a child abuse team, the orthopaedist should consider a telephone consultation with the emergency department of a local children's hospital or with a 24-hour child abuse assistance line, which most states have available. The role of the orthopaedist is usually in identifying or assessing the possibility of abuse given the pattern of skeletal injuries and then in managing the injuries. The child's primarycare physician should be contacted to ascertain whether there is any history of previous injuries in the child or siblings. Consultation with child protective services, the department of social services, and legal counsel is essential to investigate the possibility of child abuse, to assess the often complex family dynamics, and to provide legal and social protection for the child.
General surgical, neurosurgical, ophthalmologic, dermatologic, or gynecologic consultation may be necessary, depending on the child's injuries. Careful physical examination and appropriate imaging modalities are essential to rule out associated neurologic and visceral injuries. Hospital admission is often required to care for acute injuries and to provide a protected environment in which steps can be taken to diagnose and substantiate the abuse and arrange for appropriate disposition.
Many child abuse cases eventually involve legal proceedings for custodial action or criminal charges against the abuse perpetrator, which may require depositions, testimony, or court appearances by the treating physicians. The diagnostic evidence supporting physical abuse must be carefully and thoroughly documented in the medical record. Any conclusions or assessments should be based firmly on the clinical facts of the case. Even in the absence of an impartial witness or an admission to the act of abuse, the diagnosis of abuse remains an opinion. Thus, a statement regarding the level of certainty of abuse is essential. Legal consent is required for any actions to treat an abused child or to release information from the medical record. Court custody may be required when suspected family members refuse to cooperate with an investigation. The sensitive management of family violence requires both medical and legal input. Hospital child protective services teams will generally coordinate legal proceedings.
Child abuse is a pervasive social and medical problem that remains a major cause of disability and death among children. The diagnosis of child abuse involves careful consideration of sociobehavioral factors and clinical findings. Fractures are the second most common presentation of physical abuse, after skin lesions. There is no pathognomonic fracture pattern in abuse, although certain metaphyseal lesions, multiple fractures in various stages of healing, posterior rib fractures, and long-bone fractures in children less than 2 years old are suggestive of nonaccidental injury. Management should be multidisciplinary, with an emphasis on recognition, because abused children have a substantial risk of repeated abuse and death.
The authors would like to thank Carlo Buonomo, MD, and Leonard Connolly, MD, of the Department of Radiology, and Eli Newberger, MD, Director of Child Protection Services, Children's Hospital, Boston, for their assistance in the preparation of this article.
1. McMahon P, Grossman W, Gaffney M, Stanitski C: Soft-tissue injury as an indication of child abuse. J Bone Joint Surg Am
2. Akbarnia BA, Akbarnia NO: The role of orthopedist in child abuse and neglect. Orthop Clin North Am
3. National Center on Child Abuse and Neglect:Child Maltreatment 1995: Reports From the States to the National Center on Child Abuse and Neglect.
Washington, DC: National Center on Child Abuse and Neglect, 1997.
4. Sedlak A, Broadhurst DD (eds): The Third National Incidence Study of Child Abuse and Neglect: Final Report.Washington,
DC: US Department of Health and Human Services, 1996.
5. Caffey J: Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. AJR Am J Roentgenol
6. Kempe CH, Silverman FN, Steele BF, Droegemuller W, Silver HK: The battered-child syndrome. JAMA
7. Rosenberg N, Bottenfield G: Fractures in infants: A sign of child abuse. Ann Emerg Med
8. Krishnan J, Barbour PJ, Foster BK: Patterns of osseous injuries and psychosocial factors affecting victims of child abuse. Aust N Z J Surg
9. Lung CT, Daro D (eds): Current Trends in Child Abuse Reporting and Fatalities: The Results of the 1995 Annual Fifty State Survey.
Chicago: National Committee to Prevent Child Abuse, 1996, pp 1-24.
10. McClain PW, Sacks JJ, Froehlke RG, Ewigman BG: Estimates of fatal child abuse and neglect, United States, 1979 through 1988. Pediatrics
11. Lynch MA: Child abuse before Kempe: An historical literature review. Child Abuse Negl
12. Helfer RE, Slovis TL, Black M: Injuries resulting when small children fall out of bed. Pediatrics
13. Meservy CJ, Towbin R, McLaurin RL, Myers PA, Ball W: Radiographic characteristics of skull fractures resulting from child abuse.AJR Am J Roentgenol
14. Touloukian RJ: Abdominal visceral injuries in the child abuse syndrome. Pediatr Ann
15. King J, Diefendorf D, Apthorp J, Negrete VF, Carlson M: Analysis of 429 fractures in 189 battered children. J Pediatr Orthop
16. Drvaric DM, Morrell SM, Wyly JB, Miller MB, Schmitt EW: Fracture patterns in the battered child syndrome. J South Orthop Assn1992;1:20-25.
17. Akbarnia B, Torg JS, Kirkpatrick J, Sussman S: Manifestations of the battered-child syndrome. J Bone Joint Surg Am
18. Leventhal JM, Thomas SA, Rosenfield NS, Markowitz RI: Fractures in young children: Distinguishing child abuse from unintentional injuries. Am J Dis Child
19. McClelland CQ, Heiple KG: Fractures in the first year of life: A diagnostic dilemma? Am J Dis Child
20. Kowal-Vern A, Paxton TP, Ros SP, Lietz H, Fitzgerald M, Gamelli RL: Fractures in the under-3-year-old age cohort.Clin Pediatr (Phila)1992;31:
21. Loder RT, Bookout C: Fracture patterns in battered children. J Orthop Trauma
22. Beals RK, Tufts E: Fractured femur in infancy: The role of child abuse. J Pediatr Orthop
23. Dalton HJ, Slovis T, Helfer RE, Comstock J, Scheurer S, Riolo S: Undiagnosed abuse in children younger than 3 years with femoral fracture. Am J Dis Child
24. Gross RH, Stranger M: Causative factors responsible for femoral fractures in infants and young children. J Pediatr Orthop
25. Anderson WA: The significance of femoral fractures in children. Ann Emerg Med
26. Garcia VF, Gotschall CS, Eichelberger MR, Bowman LM: Rib fractures in children: A marker of severe trauma. J Trauma
27. Merten DF, Carpenter BLM: Radiologic imaging of inflicted injury in the child abuse syndrome. Pediatr Clin North Am
28. Kleinman PK, Marks SC Jr, Nimkin K, Rayder SM, Kessler SC: Rib fractures in 31 abused infants: Postmortem radiologic-histopathologic study.Radiology
29. Kleinman PK, Marks SC, Blackbourne B: The metaphyseal lesion in abused infants: A radiologic-histopathologic study.AJR Am J Roentgenol1986;146:
30. Worlock P, Stower M, Barbor P: Patterns of fractures in accidental and non-accidental injury in children: A comparative study. BMJ
31. Blakemore LC, Loder RT, Hensinger RN: Role of intentional abuse in children 1 to 5 years old with isolated femoral shaft fractures. J Pediatr Orthop
32. American Academy of Pediatrics Section on Radiology: Diagnostic imaging of child abuse. Pediatrics
33. Conway JJ, Collins M, Tanz RR, et al: The role of bone scintigraphy in detecting child abuse.Semin Nucl Med
34. Ablin DS, Greenspan A, Reinhart M, Grix A: Differentiation of child abuse from osteogenesis imperfecta. AJR Am J Roentgentol