Establishing The Cause Of A Child’s Long Bone Fracture

Long bone injuries in children

As a society, we have come a long way when it comes to safeguarding our children. The first legislation aimed at legally protecting children from abuse was not enacted until 1889 (although a succession of laws on child labour, the so-called Factory Acts, were passed in the UK throughout the 19th century). Before that, the maxim ‘spare the rod, spoil the child’ was reverently adhered to by many parents, with the full support of the state and, most importantly in past times, the Church

Now we have the Children Act 1989 which gives every child the right to protection from abuse and exploitation and the right to inquiries to safeguard their welfare. Although this and other measures are essential for protecting the most vulnerable members of our society, there have been several high-profile cases of parents being falsely accused of child abuse following the discovery of long bone fractures.

On the flip side, the media has reported several recent cases of social services and/or police failing to adequately protect children who have suffered horrendous physical abuse. In all paediatric long bone fracture cases, expert orthopaedic witnesses can provide the evidence needed to confirm abuse caused the long bone fracture or the injury resulted from another source such as an accident or underlying bone disease.

Child’s Long Bone Fracture

Causes of long bone fractures

A fracture occurs when the force exerted on a bone exceeds the ability of the bone to absorb the force. Paediatric fractures are common—approximately one third of children will have suffered a fracture by 16 years of age, with boys being more likely to break a bone than girls. Incidents of fractures peak between the ages of 11 and 15, because pubertal growth spurts cause bone mineral deposition to fall behind resulting in bones being temporarily mineral-deficient and more porous until they catch up to a child’s new size.

Metabolic bone disease of prematurity and osteogenesis imperfecta are the most frequently recognised diseases that result in infant fractures. Other underlying diseases which can cause child fractures include rickets, Cole-Carpenter syndrome, Bruck syndrome, panostotic fibrous dysplasia/McCune–Albright syndrome, osteopetrosis, infantile severe hypophosphatasia, congenital insensitivity to pain with anhidrosis, congenital rickets, and congenital cytomegalovirus infection.

A long bone fracture disproportionately caused by abuse is that of a femur fracture in children aged under 36 months. Research shows that the probability that child abuse caused a femur fracture after traffic accidents had been excluded—is 12% to 50%. In children aged under 18 months presenting with a fracture of the tibia or fibula, abuse was found to be the cause in 96% of cases. In contrast, forearm fractures in mobile children are usually accidental, often presenting as greenstick or buckle fractures caused by the child extending their forearm in order to break their fall.

What is the role of expert evidence in paediatric fracture cases?

The evidence of an expert witness is essential if the cause of a child’s fracture is uncertain and/or contentious. Radiography provides data on both suspected non‐accidental injury and suspected bone dysplasia and the British Society of Paediatric Radiology has established agreed standards for skeletal imaging in suspected non‐accidental injury. An expert witness will ensure that these and other professional guidelines are rigidly adhered to. Experienced expert witnesses also have contacts to secure high-quality imagery that is not always available to the diagnosing physician.

Bone disease can also be picked up in lab diagnosis using three routes: biochemical analysis of collagen species, mutation analysis of RNA, and mutation analysis of DNA (the first two methods require skin fibroblasts so would only be used in cases where surgical treatment was required). The ability to critically examine lab results and compare them with radiography imagery and medical history is a crucial part of an expert witness’s role and their findings can provide invaluable information to assist the court.

How can Expert Court Reports Ltd help?

At Expert Court Reports, we have several orthopaedic surgery experts who can provide evidence in child abuse and care proceedings cases. We have two orthopaedic surgeons who specialise in paediatric orthopaedic surgery: Mr David Bryson and Mr Matthew Hendersson.  However, in cases of non-accidental injuries in children, there may be other injuries which require expert evidence including abusive head trauma, and psychological harm.

Speak to our experts

Expert Court Reports provides expert witnesses and medicolegal court reports for solicitors, barristers and other agencies including the police, probation services, prisons, and third-sector organisations as well as private clients. To discuss any issues raised in this article, please call us on 01865 587865, email, or request a call by completing our online form.

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