High Specificity Features on Plain Film of Non-Accidental Injury

Adam A Dmytriw1,2, Kota Talla1, Munire Gündogan2

1 Department of Medical Imaging, University of Toronto

2 Department of Diagnostic Radiology, Dalhousie University

Objectives

  To provide an overview of non-accidental injury with respect to skeletal imaging findings

  To recognize metaphyseal lesions and posterior-medial rib fractures as high specificity findings for non-accidental injury

  To understand the common pitfalls of interpreting imaging findings for non-accidental injury

Statistics

  3 million reports of child abuse each year in USA

  >5 children die every day due to child abuse in USA

  50,000 deaths worldwide every year as a result of non-accidental injury

  True incidence of non-accidental injury likely higher due to underreporting

Mechanism

  Child held around chest and shaken violently back and forth

  Compression of chest Rib fractures

  Whiplash movement of extremities Classic Metaphyseal Lesion (CML)

  Severe angular acceleration/deceleration of head with/without direct impact Intracranial injury

Risk Factors

  History of abuse of parent

  Substance abuse by parent

  Domestic Violence

  Lack of social supports

  Low socio-economic status

  Non-ambulatory status

  Special needs child

  Multiple gestation/Preterm/Unplanned pregnancy

  Sibling with history of abuse

Early Literature

  Caffey, 1946: association between healing long-bone fractures and chronic subdural hematomas in infancy; physical abuse as cause of injuries

  Caffey and Kempe, 1962: manhandling and violent shaking as mechanisms of injury with short and long term sequelae

  Kleinman, 1989: utility of high-detail postmortem radiography in identifying skeletal injuries

Non-accidental injury

  Rate of fractures caused by abuse: estimated 11-55%

  Majority of non-accidental injury in young children, <18 months old (80%)

  Evidence of prior injuries from abuse in 50-80% of fatal or near-fatal abuse cases

  If child with non-accidental injury returns to unsafe environment, 30-50% risk of further injury and 10% risk of death

Skeletal Survey

  American Academy of Pediatrics Committee on Child Abuse and Neglect recommends a skeletal survey for a child < 24 months old with suspicion of physical abuse

  American College of Radiology also supports recommendation of skeletal survey for initial evaluation of non-accidental injury

Skeletal Survey

ACR Guidelines:

  AP / lateral skull (+ Townes if suspicious of occipital fracture)

  Lateral cervical spine

  Lateral thoraco-lumbar spine.

  Chest x ray (AP) (left / right oblique ribs)

  Abdominal x ray (AP)

  Left / right AP humeri

  Left / right AP forearm (Lat)

  Left / right PA hand

  Left / right AP femora

  Left / right AP tibia /fibula (Lat)

  Left / right AP feet

Technique

High Quality Skeletal Survey:

  Adequate spatial resolution

  High Signal to Noise

  Sufficient mAs

  Low kVp (50-70) for high contrast

  Cone to region of interest

  Monitored by RAD

  Follow up skeletal survey in 2 weeks

Bone Scintigraphy

  When skeletal survey is negative, but clinical suspicion remains high

  Requires sedation and radiation

  Diagnosis of more subtle fractures that may not be radiologically evident

  Detecting periosteal trauma and rib, spine, pelvic, and acromion fractures

  High uptake may obscure level of physis and skull fractures

Computed Tomography (CT)

  Assessment of intracranial injuries, skull fractures, solid organ, hollow viscera injury

  Requires sedation and high dose radiation

  Greater sensitivity to acute intra-cerebral and extra-axial hemorrhages than MRI

Magnetic Resonance Imaging (MRI)

  Adjunct for evaluating axonal shear injuries and dating intracranial hemorrhage

  Requires sedation, longer times, magnet availability

  Evaluating joint effusions, muscle hematomas, soft tissue edema, epiphyseal separation injuries

Fractures

High Specificity Lesions Classic Metaphyseal Lesions Rib Fractures (Post) Scapular Fractures Spinous Process Fractures Sternal Fractures

Moderate Specificity Lesions Multiple Fractures Fractures at different ages Epiphyseal Separation Vertebral body fractures and subluxations Skull Fractures Digital Fractures

Low Specificity lesions Subperiostal New bone formation Clavicular fractures Long bone fractures Linear skull fractures

Metaphyseal Corner fracture

  Whiplash-type injury at level of zone of provisional calcification

  High Specificity:

  Children who are not yet walking cannot exert such force on their on their own

Pitfalls: Metaphyseal Beak/Spur

  Beak: medial projection of metaphysis, commonly seen in proximal humerus and tibia

  Spur: longitudinal projection of bone continuous with cortex and extends beyond metaphyseal margin

Rib Fractures

  High specificity for abuse:

  PPI of Posteromedial rib # in < 3yo: 95%

Skull Fractures

  Moderately Specific for Non-accidental Injury

  Patterns: multiple egg-shell fractures, occipital impression fractures, fractures crossing sutures

  Most common: parietal bone & linear pattern

Long Bone Fractures

  Low specificity for Non-accidental injury

  Femur fracture in <1yo due to abuse: estimated 39-93%

Healing & Dating of Fractures

Time course Finding

4-10 days Resolution of soft tissue swelling

10-14 days Subperiosteal new bone formation

14-21 days Immature or soft callus, loss of fracture line definition

>21 days Mature or hard callus

Differential Diagnosis

  Accidental Injury: MVA, falls, birth trauma, CPR

  Bone Disease: Osteogenesis imperfecta ( Type 1, 4), Osteopenia of prematurity, Rickett s, Copper deficiency (Menke s Kinky) , Metaphyseal dysplasia, Syphilis, Ricketts, Scurvy , Vitamin A intoxication, Prostaglandin treatments

  Medical condition: coagulation disorder, leukemia, connective tissue disorder

Role of Radiologist

  Be familiar with characteristic imaging findings in order to raise suspicion of non-accidental injury

  Consequences of inappropriately calling:

  Under diagnosing: Delayed or no conviction, Reinjury, Death, Risk to others.

  Over diagnosing: Wrongful conviction, Harming relationships: Parent-doctor, Family, Community

Teaching Points

  Skeletal surveys in the evaluation of children < 2 yo with suspicion of abuse

  High specificity of metaphyseal lesions and posterior-medial rib fractures for non-accidental injury

  Repeat skeletal survey may be necessary

  Multidisciplinary team approach and communication with referring physician

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