Inflicted skeletal injury: a postmortem radiologic-histopathologic study in 31 infants

Abstract

OBJECTIVE. The objective of this postmortem study was to use high-detail skeletal surveys, specimen radiography, and histopathologic analysis to determine the number, distribution, and age of inflicted skeletal injuries in infants studied at the University of Massachusetts Medical Center from 1984 to 1994. MATERIALS AND METHODS. Thirty-one infants (average age, 3 months) who died with inflicted skeletal injuries were studied with high-detail skeletal surveys and specimen radiography and histopathologic analysis. The distribution and number of fractures was determined for each technique, and dating was performed on the basis of radiologic and histologic criteria. The skull fractures noted in 13 cases were excluded from the numerical analysis. RESULTS. The radiologic-histopathologic correlation revealed 165 fractures involving the ribs in 84 (51%), long bones in 72 (44%), bones of the hands and feet in 6 (4%), clavicles in 2 (1%), and spine in 1 (< 1%). Of the 72 long bone fractures, the metaphyses were involved in 64 (89%, or 39% of the total), and the shaft was involved in 8 (11%, or 5% of the total). One hundred sixteen fractures were healing, 36 were acute, and 13 were of indeterminate age. In all but two infants, at least one healing fracture was present. Of fractures diagnosed histopathologically, specimen radiography increased the yield of fractures noted on skeletal survey from 58% to 92%. CONCLUSION. Most infants who die with inflicted injury have fractures at multiple sites. Metaphyseal and rib fractures are much more common than long bone shaft injuries, the opposite of the pattern found in older children. Because most abused infants who die have evidence of healing fractures at the time of autopsy, aggressive radiologic efforts to identify these injuries in living as well as in decreased infants appear justified.