Fractures in infancy: are the bones brittle?

Abstract

Summary<ul><li>1.Children should have the right to a childhood free of abuse, but in the UK violence towards children shows no sign of diminishing. In these circumstances, whilst prevention of abuse remains the goal, paediatricians and other doctors who care for children have a responsibility to recognize abuse. The prognosis for the child and family is better if abuse is recognized early when intervention is more likely to be effective and damage to the child is, hopefully, reversible.</li><li>2.It is difficult to raise the question of physical abuse with parents. Referral to Social Services and the Police is part of a full investigation and professionals concerned with families are aware of the impact of such enquiries on family function.</li><li>3.If doctors follow usual clinical method, mistakes in diagnosis should be few. Trauma is the cause of fractures, but did the bones break with less than expected stress^{^26,27} Organic disease is rare, but there is a differential diagnosis of fractures with a growing literature to assist in a potentially complex field. Colleagues are available for their opinion.</li><li>4.The vast majority of fractures occur in children with normal bones, and the younger the child the greater the chance that the fracture was inflicted by the child's carers.</li><li>5.There is also a legal literature specifically on the debate of the role of brittle bone disease and ‘temporary brittle bone disease' in infant fractures.^{^28,29} Lynch has summarized the findings ‘…the judgement (also) affirms that the courtroom is no place to advance untested hypotheses' and continues to discuss the role of expert witnesses as an independent opinion who attempts to balance all the facts.^³⁰</li></ul>