How are healing bone injuries dated in cases of physical child abuse?

Updated: Apr 24, 2017
  • Author: Angelo P Giardino, MD, MPH, PhD; Chief Editor: Caroly Pataki, MD  more...
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Answer

Dating of boney injuries is particularly important in the evaluation of physical abuse, because it may assist investigators in determining who had access to the child in the period the injury is estimated to have occurred. The body of medical literature evaluating the precision of dating of fractures has evolved over the last decade. The classic teaching has been that fractured long bones and ribs heal in a predictable manner, which is divided into the following 4 stages: initial healing, soft callus, hard callus, and remodeling. Orthopedic aspects of bone healing are described in Forearm Fractures.

This traditional description of bone healing included general timelines for the age of the injury based on the stage of healing seen at the time of injury identification. In young children, bone healing tends to occur more rapidly than in older children and adults. Newer studies of dating of fractures, however, emphasize that the classic descriptions (eg, soft callus, hard callus) are based on histiologic specimens rather than plain film readings, and significant inconsistencies exist among radiologic interpretation of healing phases. [11] The evaluation of the healing process on plain films permits some level of dating of injuries and allows the healthcare professional to distinguish new and relatively older fractures in the same child; providers should exercise caution in precisely dating fracture age based on x-ray findings alone.

Metaphyseal fractures are generally harder to date because of the relative lack of disruption in the periosteum at the time of the fracture. Skull fractures heal differently than do long bones because of their intramembranous nature; they do not heal with a large amount of callus formation and are more difficult to date. The skills and advice of an experienced pediatric radiologist should be consulted if dating of injuries becomes central to the maltreatment investigation.


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