Are All Infant Fractures Abuse?

Can I vent a little? It seems like every time I work on an infant fracture case, I deal with the same thought process by CPS and the Child Abuse Pediatricians they employ. It is frustrating, almost maddening, how little the developing science and medical facts change the way “child protection team” doctors think. The classic thinking goes like this:

  • A non-ambulatory infant cannot injure himself / herself.
  • If there is a fracture, some adult caused it.
  • The parents cannot explain why there is a fracture.
  • When pressed for an explanation, the parents come up with explanations that we don’t believe.
  • Therefore, we have an unexplained fracture
  • An unexplained fracture in a non-ambulatory child equals abuse.

Some version of this tortured syllogism has reared its ugly head in virtually every infant fracture case I have had over the last two decades.

In addition to this flawed logic, you have the notion that some fractures can only be caused by abuse (never by accident, never by poor bone metabolism.) This notion was essentially pioneered by Paul Kleiman, M.D., in his now infamous treatise Diagnostic Imaging of Child Abuse (now in its 3rd edition.) Through the years, based at least in significant part on the work of Dr. Kleiman, doctors have accepted, with very little questioning the notion that some injuries virtually diagnose themselves. So, a corner metaphyseal lesion (CML) or a posterior rib fracture, or even a fracture of a long bone (humerus, radius, ulna, femur, tibia, fibula) are always going to be suspect for abuse by a doctor who studied Kleiman in medical school. (The first edition was published in 1987, so if your doctor was in medical school in the last three decades he/she probably thinks this is the Bible.)

Circular Reasoning Leading to the Diagnosis of Child Abuse

If a doctor starts with an understanding that your child’s injury is “pathognomonic ” or “highly specific ” for abuse, and then asks the parent for an explanation, it is not hard to predict the outcome. If the parent offers a non-abusive explanation, it will be rejected. Every time. The only explanation that will be accepted is one that conforms with the doctor's pre-formed belief. We think of doctors as science based and thoughtful people. However, a scientist does not form a belief first and then gather the facts, carefully rejecting every fact that does not support the belief. Yet, that is done every day in Michigan by doctors, CPS workers, prosecutors, police and even judges.

In the same way, if the doctor thinks an injury can only be caused by a high speed car accident or a fall from a three story building, every other explanation will be rejected. The result? Parents are prosecuted every day in Michigan for crimes that never occurred.

The simple fact is that not every fracture in an infant is caused by abuse. There are a large number of factors that need to be considered when assessing an infant fracture. Parents should not rely on the representations of emergency room physicians or doctors associated with the “child protection team.” A thorough medical evaluation should be done examining issues of bone fragility and the viability of parent reports of accidental causation.

Here are some facts that parents facing prosecution need to know:

  • There are no fractures that cannot be caused accidentally. Doctors cannot look at an x-ray, MRI or CT scan and diagnose abuse.
  • Plain film x-rays are a very poor tool for assessing bone mineralization. A hospital doctor who opines that the bones are healthy after looking at the x-rays is incompetent.
  • Child abuse pediatricians are not radiologists and are not qualified to accurately do the job of a radiologist.
  • Many children in Michigan have Vitamin D Deficient Rickets, even including some that have taken Vitamin D supplements.
  • Fragile, brittle and under-mineralized bones are often a temporary condition. If a child goes on Vitamin D or changes his diet after being taken away, the improvements in bone mineralization does not mean that the parents are abusers.
  • There is nothing unusual about a child abuse doctor providing courts with totally wrong information about the causes of fractures or the health of a child’s bones.

O.K., I am done venting. There is some good news: Parents don’t have to go through this alone. If you know a parent that is being accused of child abuse, they need two things. First, they need to hire the best attorney possible. Second, they need to have a fair and competent review of the child’s entire medical file, usually back to and including the birth records.

I have spent the last couple of decades helping parents through difficult times. I am not complaining. It is something I am passionate about. But parents deserve better than being prosecuted based on the flawed “science” of thirty years ago. Children deserve better than being taken away from parents who are falsely accused.

If you have a CPS case and need some help, don’t hesitate to call.

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