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TABLE 111.2 Fractures Strongly Suggestive of PHYSICAL ABUSE a Fractures inconsistent with history Fractures inconsistent with developmental stage of the child Fractures with associated injuries suggestive of abuse Multiple fractures, particularly in various stages of healing Skull fractures (including multiple or depressed skull fractures) Rib fractures Fractures of the femur or tibia in a preambulatory child Spiral or midshaft fractures of the humerus Metaphyseal chip (corner) fractures 10 Avulsion fractures of the clavicle and acromion process a Especially in children less than 18 months old Reproduced from Kemp AM, Dunstan F, Harrison S, et al Patterns of skeletal fractures in children abuse: systematic review BMJ 2008;337:a1518; with permission from BMJ Publishing Group PATHOLOGIC FRACTURES A fracture that occurs through abnormal bone is considered a pathologic fracture ( Figs 111.7 and 111.8 ) The predisposing condition may not become apparent until after the fracture occurs Bony tumors, hereditary diseases, metabolic disorders, neuromuscular disease, and infections can cause focal or generalized bone weakness, making it more prone to fracture Urgent orthopedic consultation should be obtained for all pathologic fractures with other specialists consulted based on the suspected underlying disease process ( Table 111.3 ) INJURIES OF THE UPPER EXTREMITIES Injuries of the Shoulder and Humerus Clavicle Fractures and Acromioclavicular Joint Injuries Goals of Treatment Fractures of the clavicle can be divided into three categories: fractures of the shaft, the medial end, and the lateral or distal portion Injuries to the lateral aspect of the clavicle must be distinguished from acromioclavicular (AC) joint injuries The majority of clavicle fractures heal without complication and with full recovery of strength and range of motion, but
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