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Unexplained Fractures in Infants - A Case for Bone Density Scans at Birth

By Attorney Elisabeth K.H. Pasqualini, Child Physical/Sexual Abuse Lawyer, Harrisburg, PA

I have previously discussed the prevailing scientific theory that rib fractures in infants and small children do not occur in non-accidental ways.  In other words, some doctors, victim-witness advocates, children and youth agencies, district attorneys and law enforcement agents believe that the presence of fractures in infants necessarily require that abuse by a caretaker occurred.  If there are fractures, then there must be abuse- or so the circular argument goes.

The Historical Pre-text for Abuse

In 1946, Dr. Caffey (the same researcher who would later hypothesize that shaking could cause intracraneal hemorragia) published a study in which he described a suspicious correlation between multiple long-bone fractures and chronic subdural hematomas in infants.  While the known association between cranial fractures and subdural hematomas seemed reasonable, Caffey had been puzzled for years about the connection between long-bone fractures and subdural hematomas.  Using x-rays (“roentgenograms”) and some simple tests of the blood and cerebrospinal fluid, Caffey expressed confidence that scurvy and localized skeletal diseases could be excluded as factors that might have predisposed the six (6) infants he examined to fractures.  In light of these facts, he concluded that the fractures had been caused by trauma that was either not observed or denied when observed. Though he stopped short of explicitly suggesting that such trauma had been intentionally inflicted, his reluctance to make such a suggestion may have been because he feared legal repercussions.

Bone Density Testing- The “Gold Standard”

Put simply– a simple x-ray, even a full body done from various angles– is insufficient to adequately diagnose the multiplicity of medical causes of bone fragility and fractures in infants and small children.  Rather, a bone density test is the gold standard upon which doctors should rely, although they are rarely, if ever done, before an accusation of abuse is made against a caretaker.

An ideal bone density test for infants is the single-photon absorptiometry method; single-photon absorptiometers (SPAs) have been widely used for many year and their use is a well substantiated technique for measuring bone density in children.  A SPA is affordable and can also be portable.  Thus, it would allow the sharing of the device among institutions. The affordability, low maintenance cost, and ease of use of a modern single photon absorptiometer should help to make bone mineral density measurements readily available. Newer single photon absorptiometers do not require handling of radioactive material and require only minimal training for operation. No trained technician is required, and single photon absorptiometers are typically used by office or clinic personnel.

Possible Results of Bone Density Tests

A bone density test done on every newborn would show any number of metabolic diseases and, therefore, negate the possibility of false accusations against caretakers.  X-rays do NOT show these issues. There is a high incidence between bone fragility, or the causes of fragility, and bone fractures.  What are some possible causes of fragility in infants?

  • Vitamin K Deficiency- linked to subdural hematoma;
  • Vitamin D Deficiency- brittle bone or osteogenisis imperfecta (OI);
  • Vitamin C Deficiency- Scurvy;
  • Rickets;
  • Osteopenia of prematurity (OP);
  • Biliary atresia;
  • Alagille syndrome;
  • Wilson’s disease;
  • Byler disease;
  • Hepatitis;
  • Thyroid dysfunction;
  • Intestinal disorders such as Crohn’s disease can impede absorption of vital minerals;
  • Ehlers Danlos syndrome type III;
  • Osteomyelitis;
  • Copper deficiency;
  • Menkes syndrome;
  • Osteopetrosis;
  • Hypophosphatasia;
  • Congenital syphilitic periostitis; and
  • Leukemia

It is imperative that any caretaker accused of abusing an infant contact competent legal counsel.  Do not simply take the word of a doctor that is relying solely upon a radiologist for confirmation of an abuse allegation based upon fractured bones.  Do not make a statement.  Rarely, if ever, will anything said to a doctor that makes a report of abuse without a bone density test will suffice as an adequate explanation.

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