Date Published: June 18, 2019
Publisher: Public Library of Science
Author(s): A. P. G. Castro, Z. Altai, A. C. Offiah, S. C. Shelmerdine, O. J. Arthurs, X. Li, D. Lacroix, Jose Manuel Garcia Aznar.
Bone finite element (FE) studies based on infant post-mortem computed tomography (CT) examinations are being developed to provide quantitative information to assist the differentiation between accidental and inflicted injury, and unsuspected underlying disease. As the growing skeleton contains non-ossified cartilaginous regions at the epiphyses, which are not well characterised on CT examinations, it is difficult to evaluate the mechanical behaviour of the developing whole bone. This study made use of paired paediatric post mortem femoral CT and magnetic resonance imaging (MRI) examinations at two different stages of development (4 and 7 months) to provide anatomical and constitutive information for both hard and soft tissues. The work aimed to evaluate the effect of epiphyseal ossification on the propensity to shaft fractures in infants. The outcomes suggest that the failure load of the femoral diaphysis in the models incorporating the non-ossified epiphysis is within the range of bone-only FE models. There may however be an effect on the metaphysis. Confirmation of these findings is required in a larger cohort of children.
Bone fractures in the United Kingdom account for 10–25% of accidental injuries in children . Of these, long bones (e.g., femur, tibia or radius) have the highest fracture rates [2–4]. A survey conducted of 382 children aged 2–14 years old found that 41.6% of fractures occurred at home . It has also been reported that 25% of injuries in children aged 12 months or younger are inflicted [6,7]. Most fractures seen in child abuse occur in children younger than 3 years old, with 80% occurring before 18 months [2,4]. The determination of whether the injuries are accidental or not depends largely on clinician’s experience, as no reliable quantitative diagnostic tools are available [3,8,9]. Diagnosing child abuse continues to be a challenging task for experienced clinicians with potential negative consequences. Reports have shown that a significant number of infant child abuse cases are at first misdiagnosed (or missed) [2,10], which may lead to further harm [9,11,12]. Given this scenario, there is a need to clarify the mechanisms of childhood injury, particularly in children yet to develop appropriate communication skills [4,6].
We used paired post-mortem CT and MRI scans of two infants (age 4 and 7 months), selected from the post mortem paediatric and perinatal imaging database of the Radiology Department, Great Ormond Street Hospital, London [31,32]. Cause of death was not disclosed. However, images were reviewed by experienced radiologists to ensure that the skeleton appeared normal on the scans. Ethical approval and parental consent were obtained for the use of these images for research purposes (LREC 13/LO/1494). At the time of the study, there were only two cases from this database having at least the proximal part of the femur clearly visible on both imaging modalities and aged under 18 months (4 and 7 months), and therefore still having a substantial portion of ossifying cartilage in the epiphysis.
The maximum principal strain distributions in the two femur models under torsion are shown in Fig 4. The maximum principal strain range on the 4 months model was 4.1×10-06 to 2.9×10-01, compared to 9.0×10-07 to 5.3×10-02 on the 7 months model. The area of high strain was located on the femoral diaphysis. The developing greater trochanter appeared to be almost strain-free, while some strain concentration appeared to build up around the epiphyses, particularly in the 4 months model. The moment to failure evaluated in these two models were compared against the values obtained from previous simulations performed exclusively on the femoral diaphysis , which yielded very similar results. The comparison of moment to fail calculations is shown in Fig 5.
This study suggests that the proximal epiphysis is not as significant for the biomechanics of the whole infant femur as has previously been speculated [20,44,45]. The comparison with FE models of bone only infant femora models  showed an agreement with the moment to fail, for both the 4 and the 7 months old subjects.