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Can rickets explain Rian Orr's rib and leg fractures?

Defense in murder trial contends 4-month-old's fractures are not evidence of prior child abuse

Posted: June 6, 2013 - 9:26pm  |  Updated: June 6, 2013 - 11:14pm

Prosecutors say fractures found on a 4-month-old baby who died with a massive brain injury are evidence of prior child abuse inflicted by the mother’s boyfriend David J. Paul, presently on trial for murder and manslaughter in Juneau Superior Court.

But as the defense began building its case on Thursday, they challenged that allegation by introducing evidence suggesting infant Rian Jambi Orr may have had rickets, a bone disorder caused by vitamin or mineral deficiencies resulting in fragile bones that fracture easily.

Dr. Patrick Barnes, head of pediatric radiology at Stanford University, testified via videoconference as a witness for the defense and said Orr’s imaging was “highly suggestive” of rickets.

One-by-one, Barnes went through images of Orr’s CT scans and skeletal X-rays pointing out characteristic signs of rickets for the jury: the thinning or softening of her skull, beading of the growth centers around her ribs called “rachitic rosary,” curved leg bones that aren’t straight as they should be and fuzzy growth centers in her arm and leg bones instead of a thin white line.

“We should see a nice thin white line across those growth centers, and they’re irregular and interrupted,” Barnes said of one of the images, “and that is a sign that we do not have normal growing bone, or the normal deposition of minerals like calcium and phosphorus at the growing ends of the bones.”

Barnes added of an apparent femur or thigh bone fracture, “That can be suspicious of a certain type of fracture that can be associated with pulling and twisting and can be due to abuse, but it can also be due to accidental injury, plus the same finding can be characteristically seen with rickets and not even represent a fracture, but look like a fracture on X-rays.”

The state’s theory is that Orr was a healthy baby until the morning of Aug. 9, 2010, when they say Paul, now 24, shook Orr after accidentally dropping her in the bathroom. (Medical testimony thus far is undisputed that being dropped did not cause Orr’s fatal head injuries.) Orr was found seizing later that morning, taken to Bartlett Regional Hospital, then flown to Harborview Medical Center in Seattle for advanced care. She died a week later on Aug. 15, 2010.

Assistant District Attorney Angie Kemp says while Paul only admitted to giving Orr “one forceful shove back,” — an admission the defense says is a false statement elicited by police tactics — there’s more to the story that he’s not telling. The prior injuries, she says, are evidence of continuous abuse.

Barnes, however, testified that he did not think shaken-baby syndrome could have caused Orr’s injuries since she did not have neck, spinal cord or brain stem injuries. Based on his review of Orr’s imaging, He said he concluded that trauma cannot be ruled out, but child abuse cannot be ruled in.

“We can’t rule out trauma — accidental or non-accidental — but from what we have we can’t rule in abuse or child abuse as a probability from the imaging findings alone,” Barnes said under direct examination from Assistant Public Defender Eric Hedland.

Barnes noted that complicating matters was the fact that MRI imaging, which he described as the “imaging gold standard,” was not done in this case while Orr was alive. State witnesses previously said that option was not available since Orr’s condition was too unstable.

Barnes added that no further imaging was done of the abnormalities, which would be required to see if the multiple rib fractures and femur fracture “represent true fractures or if they represent pseudo-fractures, or false fractures, due to bone fragility disorder.”

He said it also would have been important to test the Vitamin D levels of the mother and child, but that was not done.

Under cross-examination from Kemp, Barnes agreed that imaging is limited and that he does not have the complete medical history in the case. He agreed that inflicted trauma can lead to the kind of brain injuries Orr sustained, and that child abuse is one of the most common causes of death of children.

Also called to the stand Thursday were two social workers at Harborview Medical Center, who said they cooperated with a directive from law enforcement to restrict Paul from visiting Orr as she was dying in the hospital. None of the police officers the state called to the stand admitted to giving such a directive. The defense says the fact that Paul was prohibited from seeing Orr while the mother was given “unfettered access” goes to show police were biased in their investigation.

The social workers also testified about the parents demeanor during their week-long stay at Harborview. Alexis Miller said they both appeared scared and overwhelmed. She was asked, however, to read from a report from one of the E.R. nurses that expressed concern that the mother was not at the infant’s bedside enough and was generally “uninvolved” and “disinterested.”

Paul was seen frequently crying on and off, while Jaki was observed standing by the window, looking out and not engaging with her daughter, they said.

Kemp also continued cross-examination of the defense’s first witness, neuropathologist Dr. Jan Leestma who testified that shaken-baby syndrome “probably does not exist.” Kemp noted that Leestma penned a textbook that listed classic signs of child abuse (including the child is usually under 1 year old, multiple episodes of injury present, the presence of subdural hematomas, the child may be smaller than normal for age) which matches many signs Orr exhibited.

The defense expects to finish presenting their case early next week, at which attorneys will give closing arguments. The case will go to the jurors after that.

If convicted, Paul could be facing 99 years in prison for second-degree murder, plus another 20 years for manslaughter.

• Contact reporter Emily Russo Miller at 523-2263 or at emily.miller@juneauempire.com.

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