The presence of rib fractures in deceased infants is generally considered to be highly specific of non-accidental injury, with some pathologists considering them to be evidence of abuse. Although rib fractures may occur during resuscitative efforts in adults, the general consensus is that such injuries are exceptional in infants owing to inherent plasticity within the thoracic region. The recommendation for cardiopulmonary resuscitation (CPR) of infants since the year 2000 has been for the use of the “two-thumb” technique. However, there has been limited biomechanical investigation to what injuries may occur subsequent to this specific form of CPR. The overall aim of this thesis was to determine if two-thumb CPR can cause similar rib injuries to those seen in abusive squeezing cases. In particular, whether or not this CPR technique allows for over excessive levering of the posterior rib over the transverse process of the spine. To this end, physical experimentation simulating both two-thumb CPR and abusive squeezing was performed on an immature swine model of the infant thorax. The results of these tests did not show any significant difference in the force required to compress the thorax by one third its original anterior-posterior diameter in the two scenarios. One third being the recommended depth for CPR compressions. Fractures resultant from the testing were assessed with radiography and computed tomography, techniques commonly used by post-mortem pathologists. The type and nature of the injuries observed were remarkably similar in both scenarios. Rib injuries were primarily seen in the anterior part of the thoracic cage in both CPR and abusive specimens. The specific site of rib fracture was typically close to or within the costochondral joints. There was however an apparent absence of posterior rib fractures in the abusively tested cohort. This is in part due to the slight difference in profile of the neck and head areas within the ribs of the surrogate model. This acts to reduce the mechanical advantage offered by levering over the transverse processes of the spine. This study has shown anterior fractures of the ribs result from two-thumb CPR, challenging the long held belief that CPR cannot produce rib fractures. X-ray CT offered a significant improvement on the ability to detect costochondral junction injuries. This would offer further support to the routine use of X-ray CT in post-mortem examinations of infants where the cause of death is unknown. This has the potential to offer differential interpretation to the cause of rib injuries, especially in cases of sudden unexpected deaths in infancy, where otherwise child abuse may be diagnosed.

The classic metaphyseal lesion (CML) is considered to be a strong indicator of physical abuse in infants. These fractures extend through the metaphysis of a long bone near the growth plate, disrupting the trabecular bone structure. The mechanism(s) behind this fracture type are not entirely understood. The present study investigated experimentally the possible loading conditions required to generate CMLs in pig models. Fifty hindlegs from stillborn pigs were tested in torsion using a mechanical testing machine and a digital torque wrench. Fractures to the metaphysis that resemble CMLs were produced during a combined loading event which applied torsion to the knee joint (distal femur, proximal tibia, and proximal fibula). A visual assessment of the physeal surface of each specimen was performed after testing, and classic metaphyseal lesions were identified by comparison with findings from Love et al. (2011). The only fractures seen in both the femora and tibiae were CMLs, with both bone types having 60% (30 of 50) total fractures. The frequency of total fractures on fibulae was less, with 42% (21 of 50). The frequency of CMLs in the fibulae, however, is lower than the frequency of total fractures (38%, n=50), as physeal fractures also presented in some of those bones. Thus, the CML was the most common type of fracture produced due to the torque applied to the bones during testing. When assessing the number of CMLs that occurred on each limb, nine limbs had only one CML present, while 28 limbs had one or more CMLs. Additionally, complete CMLs made up 51.9% (41 of 79) of the total number, while partial made up 48.1% (38 of 79). Out of the 150 bones tested, 79 (52.7%) showed fractures resembling CMLs in human infants. A fracture was 35% more likely to occur in a femur or a tibia than in a fibula, and multiple CMLs per specimen were more common than single CMLs. The physeal surfaces of the specimens recorded as having CMLs showed damage to the trabecular bone. Three physeal fractures were noted; one Type IV physeal fracture on a proximal tibia and one on a proximal fibula, and a Type II physeal fracture on a proximal fibula. No diaphyseal fractures of any kind were produced. Further investigation of these conditions is encouraged to gain more insight into the injury mechanism.

No / The purpose was to determine if an age based, local diagnostic reference level for paediatric skeletal surveys could be established using retrospective data. Methods: All children below two years of age referred for a primary skeletal survey as a result of suspected physical abuse during 2017 or 2018 (n ¼ 45) were retrospectively included from a large Danish university hospital. The skeletal survey protocol included a total of 33 images. Dose Area Product (DAP) and acquisition parameters for all images were recorded from the Picture Archival and Communication System (PACS) and effective dose was estimated. The 75th percentile for DAP was considered as the diagnostic reference level (DRL). Results: The 75th percentile for DAP was 314 mGy*cm2 , 520 mGy*cm2 and 779 mGy*cm2 for children <1 month, 1e11 months and 12 < 24 months of age respectively. However, only the age group 1e11 months had a sufficient number of children (n ¼ 27) to establish a local DRL. Thus, for the other groups the DAP result must be interpreted with caution. Effective dose was 0.19, 0.26 and 0.18 mSv for children <1, 1e11 months and 12 < 24 months of age respectively. Conclusion: For children between 1 and 11 months of age, a local diagnostic reference level of 520 mGy*cm2 was determined. This may be used as an initial benchmark for primary skeletal surveys as a result of suspected physical abuse for comparison and future discussion. Implications for practice: While the data presented reflects the results of a single department, the suggested diagnostic reference level may be used as a benchmark for other departments when auditing skeletal survey radiation dose.

This diploma thesis deals with insurance protection of permanent health consequences caused by illness or in case of injury. The aim of this work was to make an analysis of the offer of accidental injury insurance in the insurance market from the potential insurance applicants? point of view and also to identify the right combination of this kind of insurance with disability pension. In this work, four best insurance products offered in the Czech market are in detail described ? Pesrpektiva 7BN insurance by Kooperativa, Flexi insurance by Česká spořitelna, Benefit and Genio insurance by Generali Pojišťovna. A simulation applied to each of the products was made and analyzed. If a client follows the simulated model, he or she should be well insured. Using the methods of multi-criteria classification (method of rank, method of points, method WSA and method TOPSIS), the best product for potential applicants has been identified. The best option seems to be the insurance product Perspektiva 7BN offered by insurance company Kooperativa.