Chief of Pediatric Radiology Uniformed Services University
of the Health Sciences Bethesda, MD and, Armed Forces Institute
of Pathology Washington, D.C.
Scope of the problem
an estimated 4 million cases
of abuse occur yearly in the US
2000 to 5000 deaths annually
brain injury leads morbidity
& mortality
64% of physically abused children
are < 5 years of age
10% of pediatric ER trauma
visits are abuse-related
10% (estimated) of unexplained
early childhood deaths are from abuse
risk of death in a physically
abused child is 5 - 25%
homicide is the leading cause
of injury-related death in young children
it is estimated that at least
10% of all patients with mental retardation and/or cerebral palsy were
in fact abused
10 - 20% of all SIDS deaths
probably represent abuse fatalities (suffocation)
infant siblings of abused children
have a 1 in 26 chance of dying of "SIDS" in Great Britain
SIDS
typically 1 to 4 month old
infant
put in crib after feeding,
later found dead (etiology remains elusive)
associated with prone positioning,
especially on "fluffy" bedding, like sheepskin
autopsy may show petechial
hemorrhages of pleura, thymus
autopsy may be entirely normal
Radiology’s role in physical
abuse
diagnosis of the abuse-related
injury, to enable prompt & appropriate care
discovery & documentation
of worrisome or specific injuries of abuse, in those both dead and alive
this discovery may be incidental
to the evaluation of a non-abuse related health problem
Findings in abuse
multiple fractures (esp. diff.
ages)
bruising ( > than expected
for age)
burns (cigarette, curling iron,
immersion, rope)
bite marks
any injury with inconsistent
history
delay in seeking care
Common radiographic findings
in abuse
long bone fractures
rib fractures
skull fractures
subdural & subarachniod
hemorrhage (blood clots on brain)
cerebral edema (brain swelling)
abdominal injury (especially
to duodenum & pancreas)
Skeletal injury
long bone fracture: shaft
long bone fracture: metaphysis
rib fracture: posterior, lateral
vertebral body compression
fracture
Long bone shaft fracture
the MOST common fracture in
abuse (4x more common than metaphyseal)
not specific for abuse . .
.
except in infants < 9 mos
old - a shaft fracture (esp. spiral) is very worrisome for abuse unless
there is convincing & verifiable history
most common in femur, humerus
Developmental milestones
4 mos raises head
5-6 mos rolls over
8-9 mos sits alone
15 mos walks alone
18 mos climbs stairs
24 mos runs well
36 mos alternates feet up stairs
Metaphyseal fracture
SPECIFIC for abuse (DIAGNOSTIC)
also called "bucket handle"
and "corner" fracture
most common at knee (distal
femur and/or proximal tibia), ankle (distal tibia), shoulder (proximal
humerus)
from whiplash & shearing
effect of shaking infant with limbs flailing
planar fracture thru most immature
part of growing bone (primary spongiosa of metaphysis)
heals QUICKLY (10 days to several
weeks): time is of the essence to discover & document this injury!!!
Radiology of metaphyseal fracture
requires individual films of
each long bone, referred to as a skeletal survey
NOT a "babygram"
meticulous attention to technique
(radiologist should supervise)
use of high-detail film
in other words, this is NOT
an on-call or "after hours" study if at all possible
these are the films that may
go to court!
What about bone scans?
they are more sensitive for
detection of rib fractures
they are less sensitive for
skull & metaphyseal fractres (& maybe vertebral body fractures)
more costly, more radiation,
more technique-dependent
all abnormalities will need
plain X-rays in addition to bone scan
Consider bone scan if:
plain films equivocal, or negative
with high suspicion
delayed workup or presentation
(metaphyseal fxs may be healed on plain X-rays but still "hot" on bone
scan)
Rib fracture
from violent shaking while
holding infant around chest
seen in 5 - 27% of abused children
90% of rib fractures are in
children < 2 years old
rib may fracture in posterior
or lateral location (or both)
Healing of fractures
allows radiologist to date
injuries
often at odds with history
given by abuser
no callus = less than 14 days
old
callus = more than 7 days old
metaphyseeal, skull, and vertebral
body fractures heal without callus - impossible to date
Brain injury
leading cause morbidity &
mortality
mechanisms:
shaking
direct blow
strangulation / suffocation
chronic repetitive injury
shaking alone is sufficient
to cause fatal CNS injury!
Injury patterns to the brain
bleeding on (subdural/subarachnoid
hemorrhage) or in brain, usually from a blow or impact, although may occur
with violent shaking alone
swelling (edema) of the brain
in the contained space (the skull vault), due to severe injury from shaking,
strangulation, blow
Interhemispheric subdural hematoma
this specific location of hematoma
is very worrisome for abuse
from shaking; brain hits against
fixed structures like falx cerebri, tentorium, skull vault
all suspected abused children
< 2 yrs should therefore have a head CAT scan
The bright cerebellum sign (aka the reversal sign)
seen in diffuse cerebral edema
(severe brain injury)
a dismal prognostic sign -
severe brain damage
very worrisome for abuse although
not specific
Skull fracture
not well correlated with abuse
injury
skull fractures are common,
but they’re also common in normal accidental trauma
features worrisome for abuse:
stellate / multiple skull fractures
fracture crosses sutures
occipital (implies significant
force)
inconsistent history ("rolled
off changing table")
skull fractures from a height
of < 150 cm are very unusual (1% fx rate)
this is much higher than a
changing table, bed, sofa, or most parent’s arms
when such fxs do occur, they
rarely have any significant underlying brain injury
Retinal hemorrhage
bleeding in retina of eye
seen in 14% of newborns; gone
by 1 month
shaking is overwhelmingly most
common cause outside of neonatal period
therefore, their presence alone
should warrant an abuse evaluation!
Abdominal injury
predominantly in childrren
> 2 years
usually from blunt trauma (punch
or kick to abdomen, rapid deceleration after being thrown)
estimated to account for 20%
of all abuse fatalities
Small bowel
duodenum & proximal jejunum
most commonly
hematoma in wall of bowel
patient presents with pain
& vomiting (hematoma in wall creates obstruction)
do upper GI study or abdominal
CAT scan
Pancreas
2nd most common cause of pancreatitis
in children is abuse
injured by blunt trauma
compressed againt spine
Other abdominal injuries
liver contusion / laceration
adrenal hematoma
bladder rupture
kidney contusion / laceration
Radiographic evaluation of
possibly abused children < 2 years of age
dedicated skeletal survey
brain CAT scan
other studies (ie., upper GI)
as symptoms warrant
Radiographic evaluation of
possibly abused children > 2 years of age
address specific symptoms
consider brain CAT or MRI scan
to evaluate for current / prior head trauma and sequela
Post-mortem evaluation
the foregoing should be done
in all suspicious childhood deaths
confer with pathologist &
radiologist to arrange skeletal survey and brain CAT scan on body
this will help pathologist
direct his/her autopsy to any additional abnormalities
autopsies do not evaluate metaphyses
may not see all rib fractures
in some jurisdictions, the
coroner is a layperson
radiographic evaluation is
a fail-safe
Child abuse
radiologists are uniquely able
to diagnose abuse
may be 1st to recognize abuse
radiographic findings in abuse
are among the most specific & diagnostic in medicine
our findings may be pivotal
to investigation & prosecution
Your job . . .
is to help ensure your patient/victim
is being evaluated thoroughly, promptly, and expertly
use your consultants; we are
here to help you in this process
you are often our ears &
eyes during the evaluation phase - we rely on your stewarship of the case