Orthopaedic aspects of child abuse.

Child abuse is one of the most serious problems encountered by on-call orthopaedic surgeons. There are adverse sequelae to both overdiagnosing and underdiagnosing this condition. Orthopaedic surgeons generally manage orthopaedic aspects of child abuse but should be aware of the associated injuries, diagnoses, prognoses, and natural history of abuse. Because fractures are the second most common presenting injury in children after skin lesions, orthopaedic surgeons are often on the front lines of treatment. No specific fracture is pathognomonic of child abuse, although some patterns, such as posterior rib fractures, metaphyseal corner fractures, and fractures in various stages of healing, are highly suggestive of abuse. Although metabolic bone disease is much rarer than child abuse, the child should be tested so treatment can be initiated, if needed, or for the purpose of demonstrating due diligence in the event of court proceedings. A diagnosis of child abuse is an understandably contentious issue; therefore, orthopaedic surgeons should be aware of injury patterns and differential diagnoses.