Unexplained Fractures: Child Abuse or Bone Disease A Systematic Review

To the editorWe read with interest the article by Pandya et al. [9].Their review of the medical literature for bone diseasesmimicking child abuse and neglect (CAN) is helpful withthe very important interpretation of unexplained fractures.However, we do not understand why the study byPaterson et al., in which they introduced a variant form ofosteogenesis imperfecta (OI) which they called ‘temporarybrittle bone disease’ (TBBD) [11], was not excluded fromthe study. Paterson et al. suggested a temporary deficiencyof an enzyme, involved in the posttransitional processing ofcollagen, as the underlying problem of TBBD in infants[11]. Others have suggested decreased fetal movement inutero might be the reason of temporary brittle bones [8].No single clinical or laboratory study supports one of thesetheories. TBBD is not clinically validated nor generallyaccepted by expert professionals [4, 5, 7].The Supreme Court in the United Kingdom concluded ina 2001 case that Paterson’s TBBD theory had no scientificbasis and the investigation was subjective, unreliable,nonscientific, and nonproven [1]. In 2004 the GeneralMedical Council removed Paterson from their registerof practicing physicians in the United Kingdom because‘‘he ignored crucial evidence to advance his own contro-versial theories on bone disease’’ [3].Paterson recently published five more cases on infantswith multiple rib fractures [10], which he presented asevidence for the existence of TBBD. Letters to the editorshowed once again the complete lack of validation for theentity [6, 12]. Crucial additional information in these cases,such as data from brain imaging, eye examinations, or acomplete skeletal survey, were not provided [10]. Therewas no review of the radiologic images by a pediatricradiologist [10]. In four cases there were no data onexamination for skin injury [10].Being unaware of the lack of scientific basis for theexistence of TBBD is dangerous, as the important evalu-ation of fractures in young children might lead to incorrectconclusions, possibly resulting in ongoing risk for the childor other children. In our opinion TBBD should be con-sidered a theory without any scientific basis. Thisbackground information should have been provided in theotherwise instructive review by Pandya et al. [9].References