Letter to the editor: Unexplained fractures: child abuse or bone disease: a systematic review.

To the Editor: In the March 2011 issue of Clinical Orthopaedics and Related Research, Pandya et al. [5] published an article entitled “Unexplained fractures: child abuse or bone disease: A systematic review”. They examined five selected studies to determine how often a bone disease is misdiagnosed as child abuse. They also determined which bone diseases are more commonly confused with child abuse and the findings that create the confusion. Of the five studies used, three were by Colin Paterson and coauthors of the UK. One of these studies is the highly criticized and controversial, “Osteogenesis imperfecta: the distinction from child abuse and the recognition of a variant form” [6]. In this study, Paterson et al. proposed the concept of temporary brittle bone disease (TBBD) by describing a series of 39 children with unexplained fractures in the first year of life. Paterson et al. proposed a diagnosis and termed it TBBD as a condition in which there was a transient predisposition to fracture with normal handing forces. The article did not provide any tests or data to support this diagnosis. In fact, many experts in the field of child abuse and neglect believe that the 39 case subjects sustained their fractures as a result of nonaccidental trauma [4, 7]. In 2004, the General Medical Council in the UK removed Dr. Paterson’s medical license citing that he was guilty of serious professional misconduct and misleading the courts during child abuse cases to promote his own theories of brittle bone disease [1]. Paterson continues to publish articles regarding TBBD although it is not accepted by mainstream pediatricians or radiologists. In the same March issue of Clinical Orthopaedics and Related Research, there is an article by Dwek which is a well-written review entitled, “The radiographic approach to child abuse” [2]. That article outlines fractures seen in the pediatric population and bone diseases. Dwek notes the theory of TBBD has been discredited and describes why it is not an accepted theory. I was surprised to see that one article correctly identified the errors and faults in a study, whereas, less than 20 pages apart, another article in the same issue uses the same study as a basis for a systematic review. When Pandya et al. used the studies by Paterson et al. for their research, they created a biased and inaccurate study. As one study used in the systematic review had faulty data and discredited information in it [6], the resulting systematic review has the same errors. I also was disappointed to read that Pandya et al., being orthopaedic specialists, regarded TBBD as an actual diagnosis. Moreover, the first study cited in the systemic review is a study from 1980 by Horan and Beighton [3]. That article was a review of notes and radiographs of patients with reported bone dysplasias. In their review, the authors found that seven of the 15 children had bone dysplasias whereas eight of the 15 children had radiographic features of “battered” babies. Unfortunately, Pandya et al. stated that Horan and Beighton looked at 13 children with six in the bone disease category and the remaining seven in the child abuse and neglect category. This is a deviation from the original study, and this error should have been detected before publication. Again, basing a study on faulty or inaccurate data creates an inaccurate and incorrect study. I was further disappointed when Pandya et al. stated that, “In many instances, a physician’s own instincts make the diagnosis [of child abuse and neglect].” It is not up to any physician to make the diagnosis of child maltreatment. A physician’s role is to have concern for child maltreatment and it is law enforcement and child protective services that have the roles of investigation and determination of child abuse. Furthermore, any child with classic metaphyseal fractures and/or posteromedial rib fractures should be evaluated for child maltreatment, even if the child has a bone disease attributable to the mechanisms required to form the fractures. Even children with bone diseases, such as osteogenesis imperfecta (OI), can be abused. Pandya et al. cited a study by Steiner et al. [8] in which it was stated that “fractures seen in OI usually involve the shaft of long bones; metaphyseal fractures do occur, albeit rarely.” Steiner et al. also stated that “when the entire context of the fracture is considered, however, the consensus of experienced radiologists and other clinicians is that the two disorders can be distinguished in a reliable fashion,” regarding bone disease and child abuse [8]. Owing to the deviation from the study by Horan and Beighton and use of the discredited study by Paterson et al. [6], the results of the study by Pandya et al. [5], are inherently incorrect. Unfortunately, this study has been published and others will likely unknowingly use the results of the study in their own reading and research. Clinicians rely on peer reviewed articles frequently. It is detrimental to the medical community when studies with poor or inaccurate data are published.