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Accidental Trauma

6.1 Introduction In children fractures are a regular occurring feature (see section 1.2). When a physician finds a fracture in a child, he can draw up a comprehensive differential diagnosis. In this chapter accidental childhood fractures are discussed.

6.2 Fractures Resulting from Birth Trauma

often diagnosed as late as several weeks after birth, due to the then present callus formation [4]. This delay in diagnosis can lead to wrongfully suspected child maltreatment. To a certain extent it is possible to differentiate between birth trauma and other trauma by evaluating the presence of callus formation. Cumming reports that callus may be visible as early as 7 days after birth [5]. When a fracture is found at an unusual location, or when 11 days after birth there is no callus visible, child abuse should be considered a possible cause.

6.2.1 General Aspects of Birth Trauma-Related Fractures

6.2.2 Incidence and Prevalence of Fractures Resulting from Birth

In older children, pain is often an indicator for the presence of a fracture. However, in neonates it is difficult to establish pain. Often the presence of a fracture can only be established by behaviour, muscle tone, heart beat and symptoms such as nausea and vomiting or limited use of a body part [1]. Fractures resulting from birth are not always diagnosed immediately post-partum, unless there are obvious symptoms, such as a clearly visible swelling and/or abnormal position. It is quite likely that physicians will completely overlook some fractures due to the lack of obvious symptoms. Research by Morris et al. showed that there was a delay in diagnosis in the majority of children that had sustained a post-partum femur fracture (section 5.7.3.1) [2]. When there are no clinical symptoms, skull fractures are also frequently overlooked, even after vacuum extraction, unless a routine radiograph was made [3]. In this study Simonson et al. found a 5% incidence of skull fractures in children born by vacuum extraction. Clavicle fractures too are

In the medical literature a great number of studies can be found on the origin of fractures during delivery (Table  6.1) [6–8]. Based on these publications it has been established that the clavicle fracture is most prevalent (Fig. 6.1), followed by fractures of the humerus (Fig. 6.2), femur (Fig. 6.3) and skull. Rib fractures are only reported in exceptional situations (see paragraph 3.5.1). Jaarsma considers the incidence of post-partum fractures to be 0.1–3.5%; however, this is an underestimation (see Sect. 6.2.1) [1]. Many of the fractures that can be caused by violence have also been reported post-partum; usually in case reports. Hence, it is essential that in the immediate post-partum period, a thorough obstetric anamnesis is taken. In their research population, Bhat et al. found a higher incidence of bone defects in cases without prenatal care, after a complicated delivery or after a Caesarean section [8]. In 2007, Groenendaal and Hukkelhoven drew attention in the Netherlands Journal of Medicine to