A possible mechanism for accidental humeral fractures in infants
A possible mechanism for accidental humeral fractures in infants
复制标题
婴儿意外肱骨骨折的可能机制
作者：
C. Jenny
Somers、Halliday 和 Chapman [1] 在他们的论文“非活动婴儿的肱骨骨折——一种可能的意外机制”中提出了骨折发生的一个具有挑战性且重要的概念。在这七起案例中，不能活动的婴儿被描述为在翻身时可能会骨折。作者认为婴儿是在伸出的手臂上滚动的。他们的解释中最令人信服的方面涉及婴儿的发育状况。当刚开始滚动时，婴儿会向两侧倾斜，然后以不受控制的动作“翻倒”。他们的背部和腹部肌肉力量很小，因此一旦他们处于躯干垂直于床面的侧卧位置，他们可能无法停止躯干的运动。正如作者指出的，当婴儿仰卧翻滚时，这一结论比相反的情况更可信。从仰卧到俯卧，很难想象支点会向骨骼的中轴施加力。雪上加霜的是缺乏婴儿骨骼生物力学知识。我们不知道一般婴儿的肱骨骨折需要多大的力，也不知道健康婴儿的正常骨强度范围。我们还没有足够的模型来研究婴儿的骨强度，并且很少向研究人员提供婴儿尸体标本[2]。这就是为什么对受伤婴儿做出最终诊断如此困难。一方面，将婴儿送回虐待环境会使孩子面临进一步受伤甚至死亡的风险。另一方面，对一个充满关爱的家庭进行不必要的干预可能会对父母及其婴儿造成伤害。由于婴儿看护者在描述儿童受伤机制时并不总是诚实可靠，因此问题变得更加复杂。作者对这些案例进行了深思熟虑、平衡的讨论，令人耳目一新，表明儿科放射学和虐待儿童儿科领域的专家可以保持客观和开放的态度。在分析疑难案件时，他们不一定急于做出判断。我想起最近的一个案例，一名小婴儿遭受不明原因的肱骨螺旋骨折。经过彻底的医疗评估后，儿童保护服务机构调查了此案，并决定婴儿可以安全地回家与父母一起，他们看起来很慈爱且合适。几周后，这名婴儿头部受伤，危及生命，导致他严重永久性残疾，完全依赖他人照顾。然而，这些噩梦般的场景不应阻止我们接受可信的偶然因果理论。在某些情况下，包括虐待儿童的诊断，任何医学领域都无法做到 100% 确定。本文的作者对婴儿骨折文献做出了重要贡献，这应该提醒我们开放的科学讨论的重要性。
In their paper, “Humeral fracture in non-ambulant infants — a possible accidental mechanism,” Somers, Halliday and Chapman [1] present a challenging and important concept for fracture generation. In their seven cases, non-mobile infants are described as possibly breaking their humeri while rolling over. The authors make the argument that the infants rolled on an outstretched arm. The most convincing aspect of their explanation involves infants’ developmental status. When just starting to roll, infants get to their sides and then “flop over” in an uncontrolled movement. They have minimal strength in their backs and abdominal muscles, so potentially they could be unable to stop the movement of their trunks once they are in a lateral position with the trunk perpendicular to the bed surface. As the authors point out, this is much more credible when an infant is prone rolling supine rather than the opposite. From supine to prone, it is harder to picture a fulcrum developing to apply force to the mid-shaft of the bone. Adding to the dilemma is the absence of knowledge on infant bone biomechanics. We do not know exactly howmuch force is required to fracture the average infant’s humerus, nor do we know the range of normal bone strength in healthy infants. We do not yet have an adequate model for investigating bone strength in infants, and infant cadaver specimens are rarely made available to researchers [2]. This is why it is so difficult to make the final diagnosis in an injured infant. On the one hand, sending a baby back to an abusive environment puts the child at risk of further injury or even death. On the other hand, intervening unnecessarily in a caring family can cause damage to both parents and their infants. The problem is complicated by the fact that infant caretakers are not always honest and reliable when describing injury mechanisms in the children. The authors’ thoughtful, balanced discussion of these cases is refreshing and shows that experts in the fields of pediatric radiology and child abuse pediatrics can be objective and open-minded. They do not necessarily rush to judgment when analyzing tough cases. I am reminded of a recent case in which a young infant sustained an unexplained spiral fracture of the humerus. After a thorough medical evaluation, Child Protective Services investigated the case and decided that the baby was safe to go home with his parents, who appeared loving and appropriate. A few weeks later the infant sustained a lifethreatening head injury that left him severely and permanently handicapped and completely dependent on others for care. Nevertheless, these nightmare scenarios should not keep us from being open to credible theories of accidental causation. No field of medicine can be 100% certain when making a diagnosis in some cases, including the diagnosis of child abuse. The authors of this paper have made an important contribution to the literature on infant fractures that should remind us of the importance of open-minded scientific discourse.