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CHAPTER 4

Body Injuries

EYE INJURIES

According to Dr. Alex Levin, “The overwhelming body of literature supports a conclusion that severe hemorrhagic retinopathy in otherwise previously well children without obvious history to the contrary (e.g. fatal head crush) suggests that the child has been submitted to abusive repetitive acceleration-deceleration trauma with or without head impact.”¹

Retinal hemorrhages (RH) are the centerpiece of eye injuries that typically occur in SBS. Such hemorrhages cannot be seen with the naked eye. An ophthalmoscope is needed to view them, because the retina is situated at the very back of the eye, behind the globe. A normal retina includes an array of blood vessels and multilayered membranes. Retinal hemorrhages that result from violent shaking events can develop in front of the membranes (preretinal or subhyaloid), between the membranes (intraretinal) or below the membranes (subretinal).

The characteristics of retinal hemorrhages can be superficial and will manifest as splinter-type or flame-type hemorrhages or larger ones that are called dot or blot-type hemorrhages. Light retinal hemorrhages can disappear from anywhere within a few days to a few weeks. The larger hemorrhages can last several weeks. Retinal hemorrhage cannot be dated with any accuracy. When SBS retinal hemorrhages are present they are typically too numerous to count and extend from the back to the sides of the retina. This is the appearance of retinal patterns of SBS. On direct observation by an ophthalmologist or via a retinal camera, SBS retinal hemorrhages have been called centrifugal—as though blood has been splattered across the entire retina.

The majority of retinal hemorrhages in shaken children are bilateral (both sides effected). One eye may have more hemorrhages than the other; having an equal number of hemorrhages in both eyes is not needed to satisfy a diagnosis of SBS.

The posterior pole of the retina is stationed at the very back, in the area where the optic nerve leads to the brain. Retinal hemorrhages in SBS commonly extend throughout the entire retina, beginning at the posterior pole and going out to the periphery (the edge of the retina). Accidental falls may produce a few retinal hemorrhages. These do not spread out, are few in number and are very light in size and shape. They are also confined to the posterior pole.

Studies have shown that the mechanism for producing hemorrhages in the retina comes from a tractional pull on the eye globe during a shaking event. The globe of the eye pulls back and forth on the retina, thus producing extensive bleeding within the retina, as well as possibly other damage.

It is believed that approximately 80 to 85 percent of infants and children who are shaken have diffuse retinal hemorrhages. In lethal cases the retinal hemorrhages are typically more extensive. Some children who are severely shaken may not have retinal hemorrhages or the hemorrhages are few and are limited to the posterior pole.

Retinal hemorrhages can appear in other types of trauma (such as birth injuries and motor vehicle accidents) or disease (blood disorders, leukemia, meningitis, etc.). But the types of retinal hemorrhages that are seen in other situations are very different from the ones seen in SBS. They are fewer in number and confined to the posterior pole of the retina. This is important to note, especially when perpetrators of shaking incidents try to explain away infant injuries as “accidental,” such as a fall from a small height. The more violent the impact on the child, the more numerous the diffuse retinal hemorrhages.

When retinal hemorrhages are diagnosed, the discovery should be a part of a larger investigation of an abusive act. Such a diagnosis should not be the basis for an immediate judgment call of abuse. Other conditions need to be considered, laboratory testing performed and medical history checked within the child’s family.

Another ocular injury that is highly specific for SBS is optic nerve sheath hemorrhage. The optic nerve extends from the brain to the eye globe. It transmits visual messages from the retina to the brain, where it is converted into meaningful information. The optic nerve is the cornerstone of human sight. To protect it, the nerve is surrounded by a membranous sheath. When bleeding underneath the sheath is diagnosed in infants and children who are being assessed for abuse, the finding is highly suggestive of a shaking case.

Repetitive acceleration/deceleration injury can directly affect the optic nerve and may ultimately cause optic nerve atrophy, which leads to permanent blindness. One reason why optic nerve sheath hemorrhage is so unique in SBS findings is the lack of correlation to short falls. There are no documented cases in the medical literature of optic nerve sheath hemorrhage that connect it to short-distance falls. So when a baby is diagnosed with this particular ocular finding, or if it is noted on an autopsy, it then becomes problematic for a perpetrator’s defense if he or she is using the excuse that the baby “fell.”

There are three other optic injuries that correlate directly with severe shaking: retinoschisis, retinal folds and vitreous hemorrhages. These are consequences that are seen in so few other conditions in childhood that they are a clear association with abuse.

RETINOSCHISIS AND RETINAL FOLDS

What are retinoschisis and retinal folds? During shaking events, it has been previously noted that tractional pulling on the eye globe is thought to be the mechanism for causing retinal hemorrhages. That same pulling or tugging causes a splitting of the retina. This separation (or schisis) is a result of the retinal traction that severe shaking brings about. A retinal fold is caused by the same means, but instead of splitting, the retina folds onto itself. Though severe, injuries such as these can be surgically corrected but some infants and children can be permanently scarred with vision loss.

There have been very few cases of accidental traumatic injury that have caused retinoschisis or retinal folds, the majority occurring from crush injuries.² In medical literature, there have been only three outlier cases of retinoschisis and retinal folds appearing in infants and children from accidental causes—one toddler reportedly had a TV fall on him³, one infant had a twelve-year-old child fall on her⁴ and a two-year-old was fatally injured by a three-story fall to pavement.⁵ All of the children died. An outlier case is one where a scenario is presented that is outside the realm of prior medical knowledge. These are highly unusual and should be investigated thoroughly. There has been some question about the veracity of the accidental cases I mentioned.

VITREOUS HEMORRHAGES

The vitreous body (eyeball) is filled with vitreous fluid—there should be no blood in the vitreous. When vitreous hemorrhage is noted, there are also commonly retinal hemorrhages. These adjacent hemorrhages can bleed into the vitreous, or the vitreous can be torn as well from the shaking mechanism. Non-accidental trauma, such as shaking, is a key reason for vitreous hemorrhages.

The final eye problem that can occur in SBS is blindness from occipital cortical damage. When a child has damage to the occipital part of the brain, it may cause lasting visual problems, since this is the area that controls how vision is processed (in the occipital lobe at the very back of the brain). The child’s pupil may have reaction to light and may be fully functioning, but the brain cannot translate the information because of occipital damage; blindness is the result.

MEDICAL DIFFERENTIAL DIAGNOSES IN SBS OCULAR INJURIES

Alex Levin, MD, one of the top child abuse ophthalmologists in the world, has listed the following medical conditions that produce retinal hemorrhages in children. This is not an exhaustive list, but the main ones that are found:

• Hypertension

• Bleeding problems/leukemia

• Meningitis/sepsis/endocarditis

• Vasculitis

• Cerebral aneurysm

• Retinal diseases (eg, infection, hemangioma)

• Carbon monoxide poisoning

• Anemia

• Hypoxia/hypotension

• Papilledema/increased intracranial pressure

• Glutaric aciduria

• Osteogenesis imperfecta

• Examinations in premature infants with retinopathy of prematurity

• Extracorporeal membrane oxygenation

• Hypo- or hypernatremia⁶

ACCIDENTAL TRAUMA DIFFERENTIAL DIAGNOSES

How can accident-related RH be seen as different from shaking RH? In 2009, Togioka and team did a PubMed search with the keywords “shaken baby syndrome,” “child abuse” and “retinal hemorrhages.” There were sixty-six articles that met inclusion criteria. They found 53 to 80 percent incidence of RH with abusive head trauma. With proven severe accidental trauma, there was a 0 to 10 percent finding of RH. They reviewed mechanisms such as convulsions, chest percussion from CPR, forceful vomiting and persistent coughing. In the absence of any other condition known to cause retinal hemorrhaging, they found .7 percent, 2 percent, 0 percent and 0 percent respectively. So when these mechanisms are offered as an excuse for the diagnosis of retinal hemorrhage (as defense experts often attempt to suggest), it has been shown to be an extremely rare occurrence. Even then, these types of hemorrhages are not the kind seen in abuse—instead, they are light, confined to the posterior pole and few in number.⁷

Let’s now look specifically at various claims that have been utilized in the courtroom in recent years:

BIRTH TRAUMA

Birth trauma retinal hemorrhages exist. In fact, they are found in 30 to 4 0 percent of all births, but they are resorbed within two to four weeks. They are also light, small and confined to the posterior pole of the eye. When a three-month-old has diffuse retinal hemorrhages and the defense asserts that these were caused by birth, there are studies that show this is not plausible.

One particularly relevant study was recently published in France. Laghmari and his group prospectively reviewed over 2,000 newborns for the presence of retinal hemorrhages. In their study, they used indirect ophthalmoscopy within twenty-four hours after birth in all newborns at various hospitals. Overall, 31.8 percent of newborns had some form of retinal hemorrhages. These hemorrhages were confined to the posterior pole of the eye and were few in number and size. Vacuum-assisted births had the largest percentage of retinal hemorrhages (38 percent) and cesarean births had the fewest (20 percent). Infants with retinal hemorrhages were reexamined weekly until the hemorrhages resolved. Annual ophthalmologic follow-up was also scheduled in these children. Their most critical finding was that two-thirds of hemorrhages had disappeared by one week after birth. Retinal hemorrhages had resolved in all newborns within four weeks.⁸

INJURIES FROM FALLS

When Dr. Betty Spivack testified in a dual appellate hearing in Kentucky to determine if SBS was a verifiable diagnosis, she discussed retinal hemorrhages. She made the statement, “Retinal hemorrhages have a much stronger correlation with abusive head trauma than unintentional head trauma, even when the unintentional injury is severe.”⁹ So, if there is a fall from a great height, there may be retinal hemorrhages seen that are similar in number and magnitude to ones seen in shaking injuries. In a study from 2008, Kivlin and associates reviewed motor vehicle crashes.¹⁰ They studied ten children, younger than three years, who died in motor vehicle crashes. Eight had retinal hemorrhages which extended to the periphery. Three of the children had retinal folds, which are more commonly associated with a diagnosis of Shaken Baby Syndrome. Six had internal membrane bleeding, but none of them had any splitting (retinoschisis). Some even had optic nerve sheath hemorrhages. But what this study found was that one can’t blame major retinal hemorrhages on a short fall, a rebleed of an underlying condition or something trivial. There needs to be a severe injury—like violent shaking.

Also from 2008, Trenchs and his researchers conducted an important study that looked at retinal hemorrhages in head trauma resulting from short falls.¹¹ There were 154 children who were studied and 80 percent of the falls were from a height equal to or less than four feet. The most common fall was from a stroller, followed by rolling off a bed. Ten percent had evidence of intracranial injury. Three children had retinal hemorrhages, all unilateral (one eye). All the hemorrhages were associated with an epidural hematoma, where there was also a midline shift to the brain. This is a severe injury where the epidural pushes onto the brain and it shifts to one side. Since only three patients had retinal hemorrhages (1.9 percent of the total), this equates to a very low chance of developing very specific retinal hemorrhages due to a low fall.

Vinchon and his team found that the lack of retinal hemorrhages in accidental falls, compared to severe findings in inflicted trauma, is statistically significant.¹² This confirmed an earlier study of his.¹³ They found that, when confessed incidents of child abuse were studied next to accidental falls in public places, the predictive value of the presence of retinal hemorrhages was 96 percent. When combined with the presence of subdural hematomas and lack of impact the predictive value was 100 percent.

Not Just a Fall

I had dropped my eighteen-month-old son off at his babysitter (my brother’s wife, Amber) that morning and headed to work. My job was within walking distance from her house. I was at work at about 8 A.M. when I heard the page from the overheard speaker. I was in a friend’s office when I picked up the call. The babysitter was panicked and said that my son was unresponsive and I needed to get over there fast. My friend could see the panic in my eyes. I told her to tell my boss that I had an emergency and ran out the door. I didn’t even stop to get my purse or my car. I ran to her house. Her neighbor had called 911. I got there just as the medics did. I ran into the house and carried him out. He was limp and mumbling and I remembered how strange his eyes looked. It wasn’t until later that I understood he was having a seizure. The medics immediately put oxygen on him and transported him to the nearby telephone company’s parking lot where we were met by the life flight team. They immediately took my son to the back of the chopper and I didn’t see him again until we reached the hospital.

Amber had two children of her own. The boy was about nine months old and the older girl was eleven. The younger child was at home when the “accident” occurred and the older one was at school. Amber told me that my son had climbed on top of the highchair, had fallen off and hit his head. I believed her. He liked to climb and getting on the lid of his highchair was nothing unusual.

The medics who were the first to arrive were very reassuring. The life flight medics were all business. I couldn’t even recognize their faces after the flight until they stopped in to see how my son was doing in the hospital. They had a huge part in saving my son’s life. When we got to the hospital he was whisked to see a pediatric internist. I remember she was very cold to me. My face was probably swollen from crying, but she seemed to have no empathy and at the time I didn’t understand why. They told me and my partner that our child had to be rushed to brain surgery. He had a massive blood clot and his brain was swelling. We waited almost eight hours with family and friends. Amber waited too and she kept repeating to us that she was so sorry. We did nothing but reassure that everything would be fine and it was an accident. When surgery was over, they allowed only me, my husband and mother-in-law to visit him. His tiny head was completely wrapped in gauze like a turban. He was on a ventilator and had so many tubes coming out of his arms. It was like something out of a nightmare. I couldn’t imagine the pain my child had endured to require such medical intervention. The nurse was angry. She pulled his diaper off and started asking me where the red marks came from. There were bruises on his waistline area that matched perfectly to the fingertips of a small hand. I started crying, saying, “I don’t know. I don’t understand. Those bruises weren’t there this morning when I left him. I didn’t do it. My son’s dad would never hurt my son.”

The nurse began to soften as she was beginning to put the pieces together that we had nothing to do with the shaking. They asked me to keep what I saw to myself and not to share it with the people in the waiting area. I was so shell-shocked I still didn’t quite understand that Amber was a suspect. I left the room to collect myself and give our family and friends an update. That is when I saw two policemen step off the elevator. My partner’s mother grabbed my arm and said they were there to find out the truth. Amber was arrested that evening. I watched them take her out in handcuffs. After that initial evening, the hospital staff changed their attitude toward my family. The care they provided to my son was exceptional. Only special people can be members of the ICU staff and we met some amazing ones. My son was in a medically-induced coma for at least ten days and he had an ICP bolt in the back of his skull to monitor the pressure. He was in the hospital from the 28th of November until the 26th of December, when he was transported to a rehabilitation facility in Bethany, Oklahoma, called the Children’s Center. He was in rehab for three weeks when they decided he would recover best in a home environment. At his time of release from rehab:

• He was beginning to crawl again.

• He could barely use his right side, due to a stroke from the blood clot.

• His eyes were not tracking properly due to retinal hemorrhages.

• He was on seizure medications, although the only seizures occurred during the hospital stay.

• He was eating thickened liquids.

• The speech therapists taught us how to teach him to sign as he was not speaking except for a few basic words: Mama, Dada, etc.

One memorable person from the hospital stay was a nurse named David. My partner’s mother called him “Negative Nancy” because he always gave us the worst possible outcome so that we didn’t get our hopes up. One afternoon he sat down in my son’s room with my husband and I and said, “Do you understand that 80 percent of marriages do not survive a tragedy like this? A special needs child can be a huge burden on a relationship.” I was feeling pretty crazy at that point so I laughed and said that we shouldn’t have any issues there, because we were not married. Neither David nor my son’s father found it to be very funny. We weren’t married at the time but after our son was released from rehab we got married on February 8, 2008. One night, probably two days into the ICU stay, my son’s pressure stats were very high. The resident on staff rushed him back to have a CT scan. When the doctor returned, he said it would be a miracle if he made it through the night. All I can remember is leaving the room, crying hysterically, and running to the chapel to pray. My husband has never been much into religion but he was right on my heels and I remember he just sat there silently with me as I cried and prayed for God to let us keep him.

A huge ice storm hit the Tulsa area while he was in the hospital. Almost all of the surrounding areas were without power. My mother-in-law and two older children were staying in a motel down the road because the power was out at my house. My son was still on a ventilator and he was being cared for by a new nurse. She was very young, probably in her early twenties. The power started flickering. I asked her what would happen if the power went out and if there was a glitch in the backup generators. I was worried he wouldn’t be able to breathe. She was on top of it and she ran and got one of those handheld CPR bags and stayed by his side until the power stopped flickering.

Amber confessed to the police officers that she became angry with my son for throwing a toy and hitting her child. That is what triggered the shaking. She confessed that she shook him upside down, which explained the bruises, and then threw water on his face to wake him up after he started seizing. This part makes my stomach turn. She had such disregard for my son that she called her sister over before she called me, and her sister called 911. My baby could have died because she was too worried about being caught. The District Attorney was pushing for fifty years in prison, because the doctors didn’t expect my son to make it. For the first week, the doctor said there was a fifty-fifty chance and if he did live he wouldn’t be the same child. His brain function might be severely limited. He might never walk, talk, etc. But he defied the odds. Though I feel this is totally wrong, the DA changed the plea deal to twenty years in prison. When Amber is released she will remain on probation for an additional twenty years. The DA wanted Amber to be in prison until she could no longer bear children. We attended every court hearing. At first she looked somber and scared. Then she turned defiant. For the last hearing a friend of mine made T-shirts with my son’s picture on the back and our titles, like Mom, Grandma and others. The judge acknowledged us during her sentencing and asked us if we agreed to the terms of the plea deal. It made us feel somewhat in control when things were so out of control.

Immediate family has become very bonded. My husband, his mom, his sister and our three kids are very close. We have become extremely protective toward all three children. My twelve-year-old did not have her first away sleepover until a few months ago. My brother and I don’t speak. He sat with his wife’s family during the court proceedings. They vehemently defended her and said she didn’t do it even though she confessed and was taking a plea deal. He abandoned my niece and nephew. A Department of Human Services social worker wanted to place them in our care as foster parents. We were good with it until they told us we would have to take them to visit their mom and I fell apart. I just couldn’t do it. My boss was going to foster them. It would have been a great environment for them. But the Indian Nation stepped in and said Indian children had to be placed with an Indian family. They ended up with Amber’s parents. I will say my husband and I have our worst arguments over our son’s care: future therapies, teacher issues, social issues. It takes a strong couple to survive something as devastating as SBS. I’m lucky to have found a true soulmate and we lean on each other. My other children suffered immensely while my son was in rehab and after. I regret it so much that their needs were pushed to the back burner, but I was so focused on making my son normal. I was so naïve to what SBS really does to the brain. His aggressive nature and quick temperament make it hard for him to have a close relationship with his brother and sister. My oldest is fifteen and he can read between the lines and calm his brother down when he is on the verge of going out of control. He is older, so I think he has more patience than my daughter. At times my daughter gets frustrated with her brother’s behavior. I try to reinforce that, no matter what, after we are gone they only have each other and they will always have to watch out for him.

My son is now seven. He has been diagnosed with ADHD and a speech disorder. He is weak on his right side and he wears an Ankle Foot Orthosis brace. He still has weekly therapies and we are always trying the latest medical interventions. He takes medicine to control the ADHD and it has significantly improved his behavior at school. He was placed in Special Ed because his behavior was out of control. Then we had a twelve-week neuro test completed that confirmed the ADHD and speech disorder. I don’t think he will ever be able to participate in a normal class, because there are too many children and it is sensory overload. Being in a support group helped me realize that it’s okay if he is not exactly like his peers. My friends who were there when the abuse occurred, who sat by us while we cried at the hospital, are incredibly loving toward him. When we make new friends with kids they don’t understand and just think he is a brat. They don’t comprehend the outbursts or the overstimulation. So it has made me intolerant and I would rather not make new friends than have my child criticized. I feel life today is wonderful, because he is here and we love him and are incredibly grateful God let us keep him with us. My husband’s mom is a godsend. She truly is an angel. She backs up our therapy decisions and takes him to his appointments while we work and he loves her so much. Someone asked me the other day if I thought my son could live a normal life and I said, “Yes, with lots of hard work.” My brother was incredibly supportive. He is a marine and was stationed in Broken Arrow when the abuse occurred. He was married with two children but still found time to visit and help with whatever we needed. He lives in Japan now with his family, but he is the only one of my siblings with whom I still communicate since my son was abused. My other brothers and sister became very divided from the SBS trauma.

My son’s abuse had a horrible effect on our lives, but we have each other and learned how to pick up the pieces and make it work. Amber’s children were affected so badly, not only by losing their mother but by their dad leaving. SBS is like a fire that just destroys everything in its path.

—Melissa Walker

OPTIC NERVE SHEATH HEMORRHAGE

As previously noted, optic nerve sheath hemorrhage is very specific to Shaken Baby Syndrome and is a common finding during an autopsy. There is bleeding below the sheath that covers the optic nerve. Bhardwaj and his team found that a diagnosis of optic nerve sheath hemorrhage in 72 percent of examined children was associated with abusive head trauma.¹⁴ This important conclusion was also confirmed by Wygnanski-Jaffe and colleagues where they showed a significantly more common association of optic nerve sheath hemorrhage and SBS (P is less than .0001, which is less than one in ten thousand cases and very significant).¹⁵

Eye findings related to SBS have been researched in greater detail in recent years. Therefore it is particularly important that physicians and ophthalmologists educate themselves appropriately on the implications of intraocular injury, because of the possibility of child abuse. Through keeping themselves up to date on the latest medical research, performing recommended examinations by the American Academy of Pediatrics and ruling out all differential diagnoses, ophthalmologists will be able to make a significant contribution as part of the interdisciplinary team that is needed to work with families and young victims.

BODY FRACTURES

When a child is shaken, it may be an isolated incident or he or she could be caught up in a cycle of abuse. Fractures are seen approximately one third of the time, depending on the type of fracture. Two of the most common are skull and rib fractures.

Skull fractures come about from impact after shaking. When a perpetrator shakes an infant, he or she may slam the infant down on a hard floor, against a wall, etc. Besides the trauma to the brain that is caused by shaking and impact, a skull fracture may occur.

There are different types of skull fracture. The most basic type of fracture is a linear one, which is a simple straight line that crosses through the full thickness of the bone. Infants and young children may sustain a depressed, or “ping-pong,” fracture due to the immaturity of the elastic skull.

The depressed skull fracture occurs when a small area of skull is displaced inwardly (much like a ping-pong ball that stays depressed when pressed upon). These types of fractures can occur when a child is hit with something or impacts against an object. Depressed fractures have also been seen when a child accidentally falls onto an object, such as a small toy. The shape of the fracture can even take on the shape of the object that has made the injury.

A comminuted fracture is one where a section of the child’s skull breaks into small pieces. This is caused by a major blow to the head. In newborns, comminuted fractures have been produced from vacuum extractions at birth, but this is a very rare event.

Growing skull fractures are associated with underlying trauma in the brain. When a mass is formed and grows, it can press against a simple linear fracture and cause it to expand. This is a rare complication of head trauma and is generally seen only in infants and young children. Growing skull fractures are considered an emergency, since the brain can herniate (or extrude) through the fracture site.

In the case of shaking, there may be signs of both old and new skull fractures, where an infant or child has been caught in a cycle of abuse.¹⁶

Skull fractures in infants and young children occur in accidental situations, but any fracture must be thoroughly evaluated by medical and law enforcement professionals to rule out abuse. Several issues must be addressed, including: timeline of injury, nature of injury, height of fall (if this is reported), hardness of impact surface, plausibility of story, underlying brain trauma (significant for abuse), type of fracture, witnessed fall, etc.

Rib fractures present a different problem for the caregiver reporting the injury, because these fractures are highly associated with child abuse. Because infants and young children’s ribs are supple, it requires a great deal of force to cause breaks in the rib bones. Typical abusive fractures of the ribs are lateral (on the sides) and posterior (in the back), because of the way that a perpetrator’s fingers grasp the child. There have been few reports of accidental rib fractures in cases of CPR, and these have occurred in the anterior (front) portion of the infant rib. There have been no reported cases of CPR-induced posterior rib fractures.

Rib fractures occur (as previously noted) in approximately 30 percent of SBS cases. During a shaking event, the perpetrator often squeezes an infant or child hard, which can cause rib fractures. When a medical exam (chest x-ray) finds rib fractures and there is no reasonable story presented by the parents or caregivers, then child abuse should be the first line of thought among medical professionals. Laboratory tests can rule out other types of medical conditions from which a child may suffer (e.g., osteogenesis imperfecta, rickets and other bone deficiencies), but abusive acts are the number one cause of rib fractures in infants and young children.

Radiologists can also determine if new or old rib fractures are present based on x-ray images. Older, healing fractures appear to have globs surrounding them, which are actually calcium deposits that formed in the healing process.

The final type of fracture that shaken babies can develop is the metaphyseal lesion. Infants and children have growth plates (epiphyseal plates) at the end of their long bones (elbows, wrists, ankles, etc.). These plates are actually growing tissues and help determine the length and shape of the mature bone when the child reaches adolescence. Growth plates are fragile and can be “fractured” by abusive acts. When a child is violently shaken, his or her arms may flail in the air, which can lead to injury of the growth plates. These types of fractures may not be seen immediately after a shaking event, so a series of x-rays may help diagnose the injuries as calcium begins to form. Metaphyseal lesions (occurring in the metaphysis [wide part] of the long bone) are also known as “bucket-handle” or “corner” fractures depending on the angle of the x-ray image. Growth plate injury can also occur from pulling or twisting arms and legs. Injuries to growth plates, depending on severity, can cause premature growth arrest and deformity.

DIFFERENTIAL DIAGNOSES IN FRACTURES

There are many diagnoses of problems, diseases and injuries in infants and young children that are known to cause fractures, including diseases such as osteogenesis imperfecta, copper insufficiency, rickets, osteomyelitis and others. These conditions can be diagnosed through lab testing and medical work-ups. When fractures are present in infants and young children (especially pre-mobile infants), the frontrunner diagnosis to be considered is child abuse. If the fracture is accidental, then the history of the injury should be appropriate for the present fracture. Was the injury witnessed? Or was it suddenly discovered? As in any potential child abuse investigation, it is vital that story of the accident be well described. A lump on the back of a five-month-old’s head, which turns out to be a skull fracture and was “just found” makes no sense. The infant’s head needed to have impacted something, or something impacted it.

CONSEQUENCES OF SHAKEN BABY SYNDROME

It is a sad and alarming fact that between 60 and 70 percent of infants identified as having been shaken are faced with dire consequences, including death. The rest may seem to recover well from being shaken but still have residual effects. Truly, the lives of not just the victims, but their entire families change as a result of a brief act of violence. Millions of dollars are spent each year in the rehabilitation of shaken infants and toddlers. The expenses include costs for equipment and services, costs for daily care and, even more importantly, emotional costs.

In the next chapter, some of the main consequences that a shaken infant may face will be discussed.