Inflicted injury (II)
Infant who
has been shakenAP radiograph of the right tibia and fibula (left) shows a faint bucket handle irregularity of the distal tibial metaphysis. Lateral radiograph of the right tibia and fibula (right) shows anterior and posterior corner irregularities of the distal tibia metaphysis.The diagnosis was a classic metaphyseal lesion (bucket handle fracture / corner fracture) of the distal right tibia in a child abuse patient.
Infant post
unexplained cardiac arrest. CXR AP shows acute fractures of the left 5th through 8th ribs laterally.The diagnosis was lateral rib fractures in child abuse.
Suspected
physical abuse • Non-accidental injury - skull fractures - Ganzer Fall bei Radiopaedia
Suspected
physical abuse • Non-accidental injury - Ganzer Fall bei Radiopaedia
Toddler who
was abused who is vomiting after eatingAP image from an upper GI exam shows diffuse persistent narrowing of the lumen of the second and third portions of the duodenum.The diagnosis was duodenal hematoma in a child abuse patient.
Infant with
respiratory distressCXR AP (left) shows the lungs to be poorly expanded and clear but there are dense areas of callus along the lateral aspect of the right 3rd-5th ribs. Centralization of the loops of bowel were also incidentally noted and confirmed on a subsequent AXR AP (right).The diagnosis was chronic right 3rd-5th lateral rib fractures and low lung volumes due to ascites which was found to be chylous when tapped in a child abuse patient.
Infant who
has been shakenAxial CT without contrast of the brain shows normal density in the rounded top of the cerebellum (in the center of the left image) compared to the diffuse low-density throughout the cerebrum. There is obliteration of the basal cisterns and loss of the normal gray matter-white matter differentiation. There is also a small left sided high density extra-axial cresenteric fluid collection that tracks medially along the entire falx.The diagnosis was diffuse cerebral edema and a left-sided acute subdural hematoma with interhemispheric extension in a child abuse patient.
Infant with
decreased responsivenessAxial (above) and coronal (below) CT without contrast of the brain shows a right moderate sized high density cresenteric extra-axial fluid collection that extends around the entire right cerebral hemisphere as well as interhemispherically. There is also a left moderate sized low-density cresenteric extra-axial fluid collection.The diagnosis was a right acute subdural hematoma and a left chronic subdural hematoma in a child abuse patient.
Toddler who
is unresponsiveAxial CT without contrast of the brain shows high density material in the subgaleal tissues posteriorly, a wide lucency in the right posterior skull along with two areas of depressed lucency in the left frontal skull, a rounded high-density lesion in the midline of the cerebellum, and decreased density of the cerebrum when compared to the normal density of the cerebellum along with loss of the normal gray matter-white matter differentiation.The diagnosis was a posterior subgaleal hematoma, a right posterior diastatic skull fracture and a left frontal depressed skull fracture, cerebellar contusion and diffuse cerebral edema in a child abuse patient.
Infant with
acute and chronic emesisAxial CT without contrast of the brain (upper left) shows bilateral large low density extra-axial fluid collections and a left frontal small high density extra-axial fluid collection. There is also prominence of the cortical sulci and the ventricular system. Axial T1 (upper right), T2 (lower left) and FLAIR (lower right) MRI without contrast of the brain better demonstrates the extra-axial fluid collections with the bilateral large collections being bright on T1 and T2 and the small left frontal collection being iso on T1 and dark on T2.The diagnosis was bilateral large chronic subdural hematomas with associated cerebral atrophy and a left frontal acute subdural hematoma in a child abuse patient.
Infant with
right hip painAP and lateral radiographs of the right femur (above) show a linear lucency through the diaphysis of the right femur with no associated periosteal reaction. CXR AP shows callus formation around the lateral aspect of the right 5th-6th ribs.The diagnosis was an acute nondisplaced fracture of the right femur and chronic right 5th-6th lateral rib fractures in a child abuse patient.
Our DDX For
This Week IsLateral radiograph of the skull shows bilateral linear parietal lucencies coursing across the skull.The diagnosis was bilateral linear skull fractures in a child abuse patient.
Infant who
has been shakenAP and lateral radiographs of the right knee shows a spur along the lateral aspect of the metaphysis which was proven at autopsy to be a spur and not a fracture.The diagnosis was a metaphyseal spur proven at autopsy in a child abuse patient.
Infant with
leg painAP radiograph of the lower extremities shows bucket handle irregularities of the metaphyses of the bilateral distal femurs and bilateral proximal tibiae. There is also periosteal reaction of the distal left femur and bilateral tibiae.The diagnosis was classic metaphyseal lesions (bucket handle fractures) of the bilateral distal femurs and bilateral proximal tibiae in a child abuse patient.
Infant with
respiratory distressCXR AP shows poorly expanded but grossly clear lungs bilaterally. There is dense periosteal reaction / callus formation around the posterior aspect of the left 8th and 9th ribs.The diagnosis was chronic left 8th-9th posterior rib fractures in a child abuse patient.
Infant with
swollen right legAP radiograph of the right femur shows a lucency through the diaphysis of the right femur with no associated periosteal reaction. CXR AP shows callus formation around the right 7th and 9th ribs laterally, the right 7th-9th ribs posteriorly, the left 3rd-7th ribs laterally and the left 8th rib posteriorly.The diagnosis was an acute displaced fracture of the right femur and chronic rib fractures of the right 7th and 9th ribs laterally, the right 7th-9th ribs posteriorly, the left 3rd-7th ribs laterally and the left 8th rib posteriorly in a child abuse patient.
Infant with a
large burn on the scalp3D CT reconstruction with contrast of the chest shows callus formation around the right 4th-8th ribs and left 4th-9th ribs anteriorly.The diagnosis was chronic right 4th-8th and chronic left 4-9th anterior rib fractures in a child abuse patient.
Toddler who
has been abusedContiguous slices from an axial CT with IV and oral contrast of the abdomen shows medial to the ascending colon the contrast-filled lumen of the duodenum narrowing to a point as it nears the midline (above) and then being narrowed as it crosses anterior to the spine (below). The diagnosis was duodenal hematoma in a child abuse patient.
Infant who
had been abusedCXR (above) and complete skeletal survey showed no evidence of rib fractures. Gross pathological image (below) shows callus formation along the posterior aspect of the left 4th-8th ribs.The diagnosis was left 4th-8th chronic posterior rib fractures which were not detected on the skeletal survey in a child abuse patient.
Suspected
physical abuse • Non-accidental injury - Ganzer Fall bei Radiopaedia
Suspected
physical abuse • Non-accidental injury - Ganzer Fall bei Radiopaedia
Suspected
physical abuse • Non-accidental trauma - Ganzer Fall bei Radiopaedia
Suspected
physical abuse • Non-accidental injury - bilateral subdural with acute blood - Ganzer Fall bei Radiopaedia
Suspected
physical abuse • Non-accidental injuries - Ganzer Fall bei Radiopaedia
Suspected
physical abuse • Metaphyseal corner fracture (bucket handle fracture) - Ganzer Fall bei Radiopaedia
Suspected
physical abuse • Skull fracture in a toddler - suspected non-accidental injury - Ganzer Fall bei Radiopaedia
Suspected
physical abuse • Non-accidental injury - intracranial injuries and skull fracture - Ganzer Fall bei Radiopaedia
Suspected
physical abuse • Metaphyseal corner fracture (child abuse) - Ganzer Fall bei Radiopaedia
Infant who is
status post cardiac arrest. Axial CT without contrast of the brain shows decreased density of the cerebrum when compared to the density of the cerebellum. There is also loss of gray matter-white matter differentiation and effacement of the cerebral sulci and the basal cisterns. There is linear increased density present along the entire falx.The diagnosis was hypoxic ischemic encephalopathy and interhemispheric subdural hematoma in a child abuse patient.
Suspected physical abuse (SPA), also known as non-accidental injury (NAI) or inflicted injury, in infants and young children represents both ethical and legal challenges to treating physicians.
Radiologists may be the first clinical staff to suspect non-accidental injuries when confronted with a particular injury pattern. Knowledge of these is essential if the opportunity to save a child from future neglect is not to be missed. At the same time, it is essential that suspicion is not raised inappropriately as the consequences for an innocent but accused parent or guardian are significant.
Terminology
Over recent years, there have been a number of titles given to the constellation of injuries that are the result of the physical abuse of children. Whilst "Non-Accidental Injury (NAI)" is ubiquitous, Suspected Physical Abuse (SPA) and Inflicted Injury (II) are the preferred terms .
Epidemiology
In 2001 an estimated 903,000 children were victims of maltreatment including:
- neglect: 57%
- physical abuse: 19%
- cutaneous injury: most common
- fractures are noted in ~30% (range 11-55%)
- sexual abuse: 10%
- psychological maltreatment: 7%
- medical neglect: 2%
Clinical presentation
A number of features have been recognized as suspicious:
- injury in the non-ambulatory/totally dependent child
- injury and history given are inconsistent
- delay in seeking medical attention
- multiple fractures with no family history of osteogenesis imperfecta
- retinal hemorrhage
- torn frenulum
- history of household falls resulting in fracture
- despite falls being common, fractures are uncommon
Specific injuries
- abdominal injuries
- thoracic injuries
Radiographic features
Skeletal injuries
A skeletal survey is performed in cases of suspected abuse to assess and document the extent of skeletal injuries. The so-called babygram (whereby the entire baby is imaged in one view) is not an acceptable substitute due to the overall lower quality that it produces; each anatomical region requires different radiographic exposures to accurately image.
Lead markers should be used in skeletal surveys and some institutions will repeat radiographs that do not have a lead marker within the primary field.
Bone scans are performed in some institutions because of their ability to detect radiographically-occult fractures.
Specific fractures
A number of fractures have been recognized as highly specific to non-accidental injuries (rather than accidental injury). They include:
- metaphyseal fracture (so-called bucket handle fracture or corner fracture)
- present in up to 39-50% of abused infants <18 months
- said to be virtually pathognomonic of NAI
- rib fractures
- especially posterior ribs
- may have no overlying bruising
- although vigorous cardiopulmonary resuscitation can occasionally cause anterior rib fractures, posterior rib fractures do not occur
- costochondral junction injuries and/or fractures
- skull fracture: suspicious features include:
- non-parietal skull fracture (a parietal fracture is more suggestive of accidental injury)
- involves multiple bones
- diastatic sutures
- crosses sutures
- depressed fracture (fracture a la signature)
- scapular fractures
- sternal fractures
- outer third clavicular fractures
Fractures which are moderately specific for NAI are :
- bilateral fractures with fractures of differing ages
- digital fractures in non-ambulant children
- vertebral fractures or vertebral subluxation
- spiral humeral fractures
- separation of epiphysis
- complex skull fractures
Fractures which have low specificity for NAI are :
- middle clavicular fractures
- linear simple fractures of parietal bone
- single fractures in diaphysis (spiral humeral fracture is an exception)
- greenstick fractures
Skeletal scintigraphy
It is the most sensitive in detecting fractures of rib, scapula, spine, diaphysis and pelvis. The test becomes positive few hours after injury. Normally there is high uptake in the epiphyses of bones which should not be confused with a fracture .
Dating injuries
The ability to date injuries is critical for medicolegal purposes and thus must be done carefully (please refer to specialist text for specific guidelines).
Traumatic periosteal injury can be seen up to 7 days post-injury (and therefore can be used for dating). Traumatic periosteal injuries can be seen on diaphyseal and rib injuries. Diaphyseal injuries start healing after one week. Healing should be complete by 12 weeks. Rib fractures are often missed, hence current practice is to repeat chest films in two weeks to observe any healing fractures. .
Metaphyseal (and costochondral junction) injuries do not heal with periosteal reaction and if visible are less than four weeks old. Skull fractures also do not heal with periosteal reaction and if seen are less than two weeks old.
Practical points
- skeletal dysplasias: one of the major - albeit uncommon - pitfalls in diagnosing NAI (e.g. Schmid-type metaphyseal chondrodysplasia, osteogenesis imperfecta I and IV), which may lack the florid features of the full-blown disease and can be easily confused with NAI
- features to differentiate osteogenesis imperfecta from NAI include
- the presence of osteopenia
- bowing or remodeling of bones
- the presence of Wormian bones
- features to differentiate osteogenesis imperfecta from NAI include
- growth plates can also cause a degree of confusion, most notably at the hip, base of the fifth metatarsal, elbow and the acromion
- birth injuries
- rickets
Siehe auch:
- Osteogenesis imperfecta
- Sternumfraktur
- Scapulafraktur
- Wormsche Knochen
- subdurales Hämatom
- Schädelfraktur
- metaphyseal fracture
- kindliche Rippenfrakturen
- Leipziger Schema
- non parietal skull fracture
- non-accidental skeletal injuries
und weiter:
- toddler fracture
- kindliche Schädelfraktur
- Infantile kortikale Hyperostose
- Duodenalhämatom
- MRT des Neugeborenen - Gehirn
- bucket handle fracture
- CHILD-Syndrom
- Glutarylazidurie Typ 1
- Deprivationssyndrom
- Osteogenesis imperfecta Typ 3
- non-accidental trauma - abdominal manifestations
- Osteogenesis imperfecta Typ 1
- anterior rib fractures
- physiologische Periostreaktion des Neugeborenen
Assoziationen und Differentialdiagnosen zu Inflicted injury (II):
