Non Accidental Trauma

In Colorado as in all of the states child abuse investigations can become the nightmare of every parent. Accidental injuries such as broken bones in an infant or small child can quickly turn even the most concerned and caring parent into a suspected child abuser.

This article explores one major area of suspected child abuse bone fractures.

Taking Your Child to the Emergency Room Triggers The Investigation of Colorado Child Abuse

Doctors, nurses and social workers are under a mandate in Colorado to report suspected child abuse. If a “pre-verbal infant or child” appears in the Emergency Room with physical injuries the attending physician will automatically order a very thorough history and physical examination.

Part of that history may result in an opinion of “suspicious findings” a situation where the child’s injuries are considered medically “inconsistent with the mechanism of the injury” (how it probably occurred). That finding may be coupled with a “hanging” or a vague history surrounding the injury may be enough to launch an aggressive and unyielding investigation that can change the lives of the people in that child’s life forever.

ER physicians have the responsibility for diagnosing child abuse. The matching of history, physical examination, radiographic findings and developmental capabilities in each case may produce an accurateor an inaccurate diagnosis of child abuse or “ non-accidental trauma.”Mistakes are made often and the stakes are very high for those who have been targeted with the very direct result of those mistakes the label of “child abuser.”

Bone Fractures in Infants and Small Children

In the ER a fracture in children under 1 year of age will raise the red flag of suspected abuse.

If there are multiple fractures, bilateral long bone fractures, fractures that are in different stages of healing, and fractures in children with developmental disabilities, the Colorado Child Protection Team of Children’s Hospita l will almost certainly be contacted.

Doctors will look at fractures of the humerus, femur and tibia as most likely evidence of an abused child and the younger the age of the child the more likely abuse will be seen as the “etiology” of the injury. An infant’s arms and legs are often used by abusive parents as a “handle” so the infant for the child to be thrown or shaken.

What About Accidental Bone Fracture Injuries in Infants and Small Children?

These same fractures in the very same regions described also occur ACCIDENTALLY, especially if the child is very ambulatory. The history of the child’s developmental milestones the likely mechanisms of injury, and the PATTERN of the fracture become key evidence in these cases.

Metaphyseal “Corner” Fractures So Called “Bucket Fractures”

Metaphyseal corner fractures are most commonly known as ‘bucket handle fractures, from the allegation that they happen as a result of a forceful shaking, or a pulling or twisting injury. It is believed that “significant force” is needed to produce this kind of fracture.

Fractures of the Hands and Feet, Ribs, Sternum and Scapular

Fractures involving the hands and feet in non-ambulatory patients such as those involving fingers and toes (metatarsals and metacarpals) also raise suspicion. Non-extremity fractures such as rib, sternal and scapular fractures are seen as requiring a high degree of force not usually the result of an accident or “accidental trauma.” Rib fractures are identified most often after they have begun to heal or “calcify” (up to 14 days to become more visable).

The Difficult Diagnosis of Child Abuse or Non Accidental Trauma (NAT) The Skeletal Survey

Physicians even Child Protection Experts agree that no one specific fracture can be considered definitive for non-accidental trauma. Fractures can be caused by abuse OR by accident. If the physician suspects abuse the first of many exploratory tests a skeletal survey must be done.

Contemporary medicine requires this basic screening study be used to begin to evaluate other fractures of abuse. It is most useful for children under two years of age where there are extremity, abdominal or head traumas. The full skeletal survey is typically repeated 14 days later.

Fractures Which Indicate To Doctors A High Degree Of Likely Abuse

Fractures are 2nd most common presentation of physical abuse (25-50%) but child abuse as in non-accidental trauma (NAT) is found in 10% of trauma cases seen in ED in children under 3.

Fractures that are commonly seen in cases of suspected non-accidental trauma “high specificity” fractures are

  • A femur fracture in a child less than 1 year old (any pattern of fracture)
  • A humeral shaft fracture in a child less than 3 years old
  • Sternal fractures
  • Metaphyseal corner (bucket-handle) fractures (see above)
  • Posterior (back) rib fractures
  • Digit fractures in non-ambulatory children
Physicians Will Zero In On Bone Fractures That Are In Various Stages of Healing Or Were Sustained at Different Times Of The Child’s Life

If the radiological bone survey of the child’s entire skeleton the survey may confirm that the child’s injuries were not caused accidentally if the survey reveals numerous fractures in various stages of healing, the attending physicians will almost immediately diagnose non-accidental trauma (NAT).

Fractures that are in various stages of healing are found in 70% of physically abused children < 1 yr and 50% of all abused children.

Some of The Risk Factors for NAT:
  • Young (age < 3 yr)
  • First born children
  • Unplanned children
  • Premature infants
  • Disabled children
  • Stepchildren
  • Single-parent homes
Areas Of The Investigation Questions In The ER

These are some of the questions physicians will address in their investigation of alleged child abuse:

  • Has there been a delay in seeking medical treatment?
  • Is the parent reluctant to give an explanation?
  • Is the injury consistent with the explanation given?
  • Does the story change between caregivers? Between child and caregiver?
  • Is there substance abuse in the home?
  • Are these the children of parents who were abused?
  • Is the abused child overly compliant and passive or extremely aggressive?
  • Is the affect inappropriate between the child and the parents? (lack of concern, overly concerned)?
  • Is the family high stress such as (loss of job, etc..)?
  • Evidence of drug or alcohol abuse?
  • Parents in an abusive relationship?
  • Has there been poor compliance with past medical treatment?
  • Was The Child born to adolescent parents?
  • Does the child have colic?
Defending Against False Accusations of Child Abuse In Colorado Some Information “Mimickers” False Charges Of Child Abuse Where The Injuries Are the Result of Another Source

Here is the rub -even when there is suspected child abuse a so called “abusive etiology” the real reason for the injuries may be from genetic, nutritional, or metabolic reasons. Significant injuries may be the result of such “mechanisms” as metabolic bone disease such as rickets, nutritional deficits such as vitamin C deficiency causing scurvy, skeletal dysplasia such as osteogenesis imperfecta, infections such as osteomyelitis, and even malignancies such as leukemia.

Other sources of injuries can be vleeding disorders, photodermatitis, salicylate ingestion, Henoch-Schonlein purpura, vasculitides, and even “Mongolian spots” are commonly mistaken for non-accidental bruising.

Why the “Science” Of Suspected Child Abuse Must be Constantly Challenged The Myth of the Spiral and Tibia Fractures

One of the most commonly held myths of fractures attributable to child abuse si the myth of the “Spiral Fracture.” In the past spiral fractures were believed to have a high association with NAT. Today it is well accepted that spiral fractures are also commonly seen in accidental fracture patterns. A small child’s bone is the weakest in a “tension/torsion” failure mechanism and a spiral fracture can occur accidentally. Additionally toddlers also fracture their tibia (lower leg bone) commonly as a result of an accidental injury.

Compare Femur Fractures

To demonstrate the divisions of thought in this area are always changing it is believed that femur fractures (upper leg bone from the knee to the hip) are specific to child abuse (60% to 70%) if the child is under 1 years old BUT considered accidental if the child is more than 1 years old. (60% to 70%)

The Solution may be a Test Called a Bone Density Test

One of the most reliable methods to determine whether there are bone density issues in an alleged victim of child abuse is to require bone-density tests- not just x-rays. This test should be administered in every case where unexplained fractures are to be used as evidence of child abuse. The “best evidence” of why bones have fractured are the bones themselves. A bone density test definitively establishes whether an infant with fractures actually does have low bone density and is therefore prone to bone fractures.

A bone-density scan should be performed as soon as suspect fractures are identified. If too much time passes between the incidence of the fractures and the scan, bone mineralization in the infant at the time of the bone density scan might be different than the bone mineralization at the time of the fractures. Also tests for OI and other collagen disorders should also be administered separately, since infants with OI have normal bone density in spite of the fragility of their bones.

The “Medical Conclusion” That Leads to Being Charged With Felony Child Abuse in Colorado

Several years ago in a case known as the Durand case out of Rhode Island Mississippi, a four-month-old was injured. The Rhode Island court that heard Durand’s appeal upheld the conviction based on this conclusion … since there was “no fact or circumstance . . . tending in any way to support any other reasonable explanation of these injuries except that they were inflicted by its parents [since no] other person is shown to have had the custody or care of the infant save its parents.

It is precisely this kind of conclusion that requires a frontal assault on the evidence by the Defense.

“Ruling Out” Non-Accidental Trauma (NAT)

Ruling out ANY accidental causes of a child’ s injuries means exhausting all possible explanations for those injuries. Bone fractures in very young infants, especially certain fractures of the clavicle, the humerus, or the femur, are well known to be caused by birth trauma. Skull fractures also often occur during difficult deliveries. Other possible congenital or acquired disorders can also account for bone fractures. For example (OI) osteogenesis imperfecta is among the most common. OI is a congenital disorder that causes severe bone fragility that almost always and can lead to fractures, even if an infant or a child is in a highly protected environment.

Other reasons for infant and child bone fractures include: accidental trauma (of course), metabolic bone disease (rickets, etc.), birth trauma and physiologic periostitis, premature birth and osteopenia of prematurity, biliary atresia, alagille syndrome, Wilson’s disease, byler disease, and hepatitis.

Summary Colorado is a Mandatory Reporter State

While all states require reporting of suspected cases of child abuse by medical professionals, Colorado actually criminally charges a professional who does NOT report suspected child abuse. If the report is made Colorado law provides legal immunity from civil or criminal liability for reporting in good faith..

What that means is that there are many more reports of suspected child abuse than almost any other crime. You need to mount an aggressive and intelligent defense to these charges should they be filed against you.

The reality of Colorado child abuse cases is that if you are convicted of child abuse you are more likely to serve a longer prison sentence than many other kinds of crimes. There is great risk in retaining a criminal defense attorney who is not experienced in child abuse investigations and prosecutions.

Juries do not like the charge of child abuse case and even though the burden of proof in these cases is the same as in every other criminal case (beyond a reasonable doubt) the jury WILL want to hear the defense case and will expect more from the defendant to prove his or her innocence than just attack the State’s case.

Any experienced and skilled Colorado criminal defense attorney knows that child abuse allegations require a proactive and aggressive approach- hire a firm that will intelligently defend you at every stage of the case from investigation through trial.

Call a Child Abuse Defense Lawyer in Denver Colorado Colorado Child Abuse Investigations Non Accidental Trauma Defending Against Questionable Bone Fractures

If you found any of the information I have provided on this web page article helpful, please click the Share buttons for Twitter and Facebook so that others may also find it.

38 Years of Experience About The Author: H. Michael Steinberg Email The Author. A Denver Colorado Child Abuse Criminal Defense Lawyer or call his office at 303-627-7777 during business hours or call his cell if you cannot wait and need his immediate assistance 720-220-2277.

If you are charged with A Colorado crime or you have questions about the topic of this article Colorado Child Abuse Investigations Non Accidental Trauma Defending Against Questionable Bone Fractures, please call our office. The Law Offices of H. Michael Steinberg, in Denver, Colorado, provide criminal defense clients with effective, efficient, intelligent and strong legal advocacy. We can educate you and help you navigate the stressful and complex legal process related to your criminal defense issue.

H. Michael Steinberg, is a Denver, Colorado criminal defense lawyer with over 38 years of day to day courtroom experience specializing in Colorado Criminal Law along the Front Range. He will provide you with a free initial case consultation to evaluate your legal issues and to answer your questions with an honest assessment of your options. Remember, it costs NOTHING to discuss your case. Call now for an immediate free phone consultation.

Helping Clients To Make Informed Decisions In the Defense of Colorado Criminal Cases

Contact A Lawyer with Three Decades of Experience as a Denver Criminal Attorney at The Steinberg Colorado Criminal Defense Law Firm today.

Colorado Defense Lawyer H. Michael Steinberg provides solid criminal defense for clients throughout the Front Range of Colorado including the City and County courts of Adams County, Arapahoe County, City and County of Boulder, City and County of Broomfield, City and County of Denver, Douglas County, El Paso County Colorado Springs, Gilpin County, Jefferson County, Larimer County, and Weld County,…. and all the other cities and counties of Colorado along the I-25 Corridor… on cases involving …Colorado Child Abuse Investigations Non Accidental Trauma Defending Against Questionable Bone Fractures.

Client Reviews
"Mr. Steinberg provided my family with expert handling of my son's case. He took extra time understand the case, to consult with us during the pretrial proceedings, and to support him for a plea agreement. Mr. Steinberg is very knowledge about the law and very professional. He guided us in achieving the best possible outcome for my son. If I am ever in need of law services again, I will certainly have Mr. Steinberg handle my case. l also highly recommend his services to anyone that might be in need of an excellent defense attorney!" Tanya Witt
"I found myself in criminal trouble, that I wasn't guilty of and thanks to Mr. Steinberg's dedication and hard work, right before we we're looking at having to continue on to trial level Mr. Steinberg was able to use his vast knowledge of the law and his many respected years in the system to find a way to show my innocence. After a very unsure and somewhat difficult time for me, this very skilled and knowledgeable attorney was able to find the right path to take to reach a dismissal in my case. For that I can't tell you how much I appreciate his representation and his excellent understanding and helpful personality. He's a great man and an even better attorney but don't misunderstand him, he is an attorney not a therapist. Thanks H." Josh
"Working with Michael Steinberg was a wonderful experience. Truly people need to know that he is a expert in what he does. His personality is compassionate, intellectual, and down to earth. I glean that Michael is fun to be around. In the time I worked with him, it was a pleasure to be around him. As for my case, the outcome was amazing and couldn’t be better. He has made my life more manageable because of the outcome of my case. I’ve worked with other lawyers in the Denver area. He is superior to them all. If you’re in need of a lawyer and you come across Mr. Steinberg look no further he’s going to be the one you need. Thank you again Michael." Renee Taylor
Mr. Steinberg, It has been an honor working with you. I very much appreciated your style, demeanor, patience, and determination. I was well instructed in every step of the court process, and I felt that I received excellent guidance and timely information regarding my case. You have been extremely thoughtful with your time, and I was very impressed with your sensitivity in responding to my requests. Thank you. Anonymous