Trauma forensics is the concept of examining trauma from a medicolegal standpoint in a given jurisdiction. Blunt and sharp force traumas are classified based on the different mechanisms of causation, which have a medicolegal significance. Adopting a standard approach to the medical evaluation of such injuries in patients would serve both the purposes of rendering appropriate treatment and the documentation and preservation of medical evidence. However, most trauma cases are seen by medical practitioners with very limited forensic knowledge and skills, and they are still expected to meet the needs of the court or the judicial mechanism in subsequent legal proceedings. Therefore, some measures, including 10 practical considerations, which are applicable in attending to blunt and sharp force traumas, would limit the risk a clinician faces in the crossfire of medicine and law.

Trauma Forensics in Blunt and Sharp Force Injuries

In dit hoofdstuk wordt toegelicht wat er wordt bedoeld met toegebracht schedelhersenletsel (TSHL) bij kinderen onder de 5 jaar oud. Vervolgens wordt uitgelegd wanneer er aan TSHL moet worden gedacht en hoe een vermoeden verder onderzocht dient te worden. Tot slot gaan we in op de differentiaaldiagnose en de alternatieve verklaringen van subdurale bloedingen en retinabloedingen. 

Toegebracht schedelhersenletsel bij kinderen

PURPOSE OF THE STUDY
The primary aim is to assess the proportion of children younger than two years with a femoral fracture who underwent a skeletal survey. The secondary aim of the study is to evaluate the patients' demographics, reported trauma mechanism, type of fracture, type of treatment and complication rate. MATERIAL AND METHODS This was a retrospective study of children younger than two years examined at the Department of Imaging Methods for a femoral fracture between 2015-2022. The type and site of the fracture were assessed on radiographs. The patients' medical records were used to assess which steps had been taken to evaluate for possible abusive etiology of the fracture. The data were correlated with the published guidelines for performing skeletal survey in young children with fractures. The patients' demographics, medical history, time interval from trauma or symptoms onset to medical examination, type of treatment, duration of orthopaedic follow-up in addition to the clinical fi ndings at the last orthopaedic follow-up visit were also retrieved from the patients' medical records. RESULTS A total of 40 children were included in the study, 21 of whom were girls (52.5%). The mean age was 13.8 months. 5 children (12.5 %) were younger than 6 months. 36 children (90%) had a history of trauma, the vast majority of whom suffered a fall. 21 patients (52.5%) sustained a distal metaphyseal fracture, 19 patients (47.5%) suffered a diaphyseal fracture. A spica cast was used in 12 patients (30%), which was applied under general anaesthesia in most cases. 28 patients (70%) received a long leg cast. A certain degree of stiffness following cast removal was the only documented complication. Based on the published guidelines, it was estimated that in 23 patients (57.5%) a skeletal survey should have been performed. However, this investigation was performed in 2 patients (5%) of the study population only. DISCUSSION Femoral fractures in young children are rare, especially in those younger than six months of age. The fractures were located in femoral diaphysis and in distal femoral metaphysis. Surgical treatment was not required, and no signifi cant complications were observed. Nonetheless, the study showed that the rate of child abuse screening was low. The skeletal survey was performed in two cases only, both children were younger than six months and had no history of trauma. Based on the published guidelines, however, it may be assumed that the skeletal survey should have been performed in more than half of the patients in the study. The failure to perform this investigation might have led to the abuse not being detected and the child being returned to the abusive environment. CONCLUSIONS Management of femoral fractures in patients younger than two years does not usually require hospitalisation and is not associated with the risk of complications. However, potential further harm may be caused if abusive etiology of the femoral fracture fails to be discovered. This study has shown that the rate of abuse evaluation is low. It is essential to initiate a multidisciplinary discussion on this topic to raise the physicians' awareness and to implement the screening for child abuse among young children with femoral fractures. This scientifi c paper also includes a summary of necessary steps to be taken in the evaluation of a young child with a femoral fracture.


KEY WORDS
fractures, femur, children, infant, child abuse, radiography.

[Femoral Fractures in Children Younger than Two Years. Are We Considering Abusive Etiology?]

Homicide is a leading cause of death for American children. We hypothesized demographics and homicide circumstances would differ by victim age. 

Pediatric Homicides: Not Just a Teenage Problem

Dit hoofdstuk bespreekt een weinig voorkomende maar ernstige vorm van fysieke kindermishandeling: het buiktrauma. Intra-abdominale letsels zijn na (intra)craniële letsels de meest voorkomende oorzaak van overlijden als gevolg van kindermishandeling. Dit hoofdstuk beschrijft op systematische wijze de schade die aan verschillende organen kan ontstaan en hoe deze kan worden herkend. De redenen voor de hoge mortaliteit bij intra-abdominale letsels zijn de specifieke kwetsbaarheid van kinderen, zoals door relatief grote organen en een dunne buikwand, en de vaak late presentaties bij het snel ontstaan van hemodynamische problemen bij bloedingen. 

Buiktrauma bij fysiek geweld

The prevalence of non-accidental trauma among children with polytrauma: A nationwide level-I trauma centre study.

The prevalence of inflicted femur fractures in young children varies (1.5-35.2%), but these data are based on small retrospective studies with high heterogeneity. Age and mobility of the child seem to be indicators of inflicted trauma.This study describes other factors associated with inflicted and neglectful trauma that can be used to distinguish inflicted and neglectful from accidental femur fractures.This retrospective study included children (0-6 years) who presented with an isolated femur fracture at 1 of the 11 level I trauma centers in the Netherlands between January 2010 and January 2016. Outcomes were classified based on the conclusions of the Child Abuse and Neglect teams or the court. Cases in which conclusions were unavailable and there was no clear accidental cause were reviewed by an expert panel.The study included 328 children; 295 (89.9%) cases were classified as accidental trauma. Inflicted trauma was found in 14 (4.3%), while 19 (5.8%) were cases of neglect. Indicators of inflicted trauma were age 0-5 months (29%, positive likelihood ratio [LR +] 8.35), 6-12 months (18%, LR + 5.98) and 18-23 months (14%, LR + 3.74). Indicators of neglect were age 6-11 months (18%, LR + 4.41) and age 18-23 months (8%, LR + 1.65). There was no difference in fracture morphology among groups.It is unlikely that an isolated femur fracture in ambulatory children age &gt; 24 months is caused by inflicted trauma/neglect. Caution is advised in children younger than 24 months because that age is the main factor associated with inflicted trauma/neglect and inflicted femur fractures. 

/pdf/prevalence-of-inflicted-and-neglectful-femur-shaft-fractures-8q2bb2ia.pdf

Prevalence of inflicted and neglectful femur shaft fractures in young children in national level I trauma centers

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The prevalence of non-accidental trauma among children with polytrauma: A nationwide level-I trauma centre study.

Prevalence of inflicted and neglectful femur shaft fractures in young children in national level I trauma centers