Evaluation of Fracture Without Known Trauma: Use of DXA in Differential Diagnosis

Abstract

The possibility of physical child abuse or nonaccidental injury (NAI) has to be considered whenever an infant or child presents with multiple fractures. Clinicians have a duty to exclude accidental injury as well as any underlying medical disorder associated with diminished bone strength that can lead to fracture. Osteogenesis imperfecta (OI) is the most common bone disorder considered in the differential diagnosis of a young child with unexplained fractures. For the majority of children with unexplained fractures, the diagnosis of NAI or OI can be reached with a detailed clinical history, a thorough clinical examination by a clinician experienced in bone disorders, and a skeletal survey interpreted by an experienced pediatric radiologist. DXA measurements rarely help to distinguish healthy infants who have been victims of abuse from those with milder types of OI. This chapter reviews role of bone densitometry in discriminating between healthy infants and children with possible NAI from those with OI. Details are also provided on non-ambulant children with cerebral palsy and those with congenital insensitivity to pain who are prone to fragility fracture.