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We would like to thank the authors from the field of forensic medicine for their critical feedback on our article (1).

The aim of our article was to create increased awareness in emergency departments and community-based medical practices of the possibility that fractures in children are the result of physical abuse (or neglect). Our intention was to help doctors working in these settings to ask the right questions and initiate a thorough diagnostic evaluation, if required. It is definitely beyond the scope of such an article to already answer all these questions. This is the responsibility of specialized bodies, for example at the institutes of legal and forensic medicine. We pointed this out in our Introduction, in the section “What to do if indications of abuse are substantial” and in the Key Messages.

E-mails and telephone calls we have received after the publication of our review indicate that the goal of a critical assessment of childhood fractures has already been achieved at some sites.

Prof. Mützel and Dr. Banaschak describe our statement that linear skull fracture can occur after a fall from a low height as incorrect. To support this claim they cite a chapter from a book published in 2001. However, in the more recent edition published in 2009 (2), the occurrence of linear skull fractures after (partially in hospitals) observed falls from a height of 3 feet (approximately 91 cm, so-called “short falls”) is reported to be 0.8% to 1.3% (3). Furthermore, the force required to produce a skull fracture is described as “low to moderate“. It seems that at this point the misunderstanding occurs: As clinicians, these children are presented to us only after a selection process. Falls in children are everyday events. Approximately 1% of falls have consequences; thus, these cases will regularly occur in large cities, such as Munich, Cologne or Berlin, and be especially prevalent in large pediatric emergency departments. Of course, this alone does not allow to draw the conclusion that a linear skull fracture is unlikely caused by abuse. History, motor skills and all accompanying findings have to be as carefully evaluated as with other childhood fractures.

Likewise, the alleged improper dealing with the case series of Atkinson et al. (4) is something we cannot leave unchallenged. Banaschak and Mützel claim that Atkinson et al. had not scrutinized the information provided about the accidents. However, in the article’s Methods section the inclusion criterion is clearly stated: Apart from evaluation of a child protection physician, it was a requirement that in addition the examinations of the youth welfare office and the police had to arrive at the conclusion that it was not a case of abuse. We specifically included this study to illustrate how challenging the comprehensive evaluation of an injury can be in individual cases so that a multiprofessional evaluation of these cases (including forensic medicine) is crucial.

In their letter, Dr. Adamec and Prof. Graw criticize that we had analyzed more articles in full text than we cited. However, we think that this is per se a defining feature of selective reviews of the literature and meets the requirements of the Deutsches Ärzteblatt (the 40 most important references in the printed version and any indispensable further references as eReferences online).

That the authors of the letters regard our article as inadequate for physicians actively involved in child protection is in our view the result of the misunderstanding with regard to the target group for our article which we have already mentioned at the beginning of our reply.

Because of the set size limit for review articles, there was little room for biomechanical considerations which were only intended to demonstrate to the readers in medical practices and emergency departments which thoughts must precede the critical evaluation of the history of the fracture.

For further reading we referred, among others, to the work of Bilo et al. (5), cited also by Mützel and Banaschak.

Overall, we see in the correspondence the common goal that children with fractures nationwide require a careful diagnostic assessment to recognize or rule out potential abuse—a task which we think rather requires a combined effort than overemphasis on disciplinary boundaries.

DOI: 10.3238/arztebl.2019.0146c

Corresponding author

Oliver Berthold

Kinderschutzambulanz, DRK Kliniken Berlin-Westend, Berlin, Germany

o.berthold@drk-kliniken-berlin.de

Conflict of interest

The author declares no conflict of interest.

1.
Berthold O, Frericks B, John T, Clemens V, Fegert JM, von Moers A: Abuse as a cause of childhood fractures. Dtsch Arztebl Int 2018; 115: 769–75 VOLLTEXT
2.
Rorke-Adams L, Duhaime CA, Jenny C, Smith WL: Head Trauma. In: Reece R, Christian C (eds.): Child abuse medical diagnosis & management. Itasca, Illinois, USA: American Academy of Pediatrics 2009.
3.
Nimityongskul P, Anderson LD: The likelihood of injuries when children fall out of bed. J Pediatr Orthop 1987; 7: 184–6 CrossRef
4.
Atkinson N, van Rijn RR, Starling SP: Childhood falls with occipital impacts. Pediatr Emerg Care 2018; 34: 837–41 CrossRef MEDLINE
5.
Bilo RAC, Robben SGF, Rijn RR: Forensic aspects of pediatric fractures: differentiating accidental trauma from child abuse. Berlin, Heidelberg: Springer 2010 CrossRef
1.Berthold O, Frericks B, John T, Clemens V, Fegert JM, von Moers A: Abuse as a cause of childhood fractures. Dtsch Arztebl Int 2018; 115: 769–75 VOLLTEXT
2.Rorke-Adams L, Duhaime CA, Jenny C, Smith WL: Head Trauma. In: Reece R, Christian C (eds.): Child abuse medical diagnosis & management. Itasca, Illinois, USA: American Academy of Pediatrics 2009.
3. Nimityongskul P, Anderson LD: The likelihood of injuries when children fall out of bed. J Pediatr Orthop 1987; 7: 184–6 CrossRef
4.Atkinson N, van Rijn RR, Starling SP: Childhood falls with occipital impacts. Pediatr Emerg Care 2018; 34: 837–41 CrossRef MEDLINE
5.Bilo RAC, Robben SGF, Rijn RR: Forensic aspects of pediatric fractures: differentiating accidental trauma from child abuse. Berlin, Heidelberg: Springer 2010 CrossRef

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