High Specificity Features on Plain Film of Non-Accidental Injury

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Clement Houston
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2 1 Department of Medical Imaging, University of Toronto

1 High Specificity Features on Plain Film of Non-Accidental Injury Adam A Dmytriw 1,2, Kota Talla 1, Munire Gündogan 2 1 Department of Medical Imaging, University of Toronto 2 Department of Diagnostic Radiology, Dalhousie University

$rib fractures as high specificity findings for non-accidental injury To understand the common pitfalls of interpreting imaging findings for non-accidental$

2 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

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

$Mechanism Child held around chest and shaken violently back and forth Compression of chest Rib fractures Whiplash movement of$

4 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

5 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

$Early Literature Caffey, 1946: association between healing long-bone fractures and chronic subdural hematomas in infancy; physical abuse as cause of injuries Caffey and Kempe, 1962:$

6 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

$Non-accidental injury Rate of fractures caused by abuse: estimated 11-55% Majority of$ injuries from abuse in 50-80% of fatal or nearfatal abuse cases If child with

injuries from abuse in 50-80% of fatal or nearfatal abuse cases If child with

7 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 nearfatal 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

8 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 nonaccidental injury

$Skeletal Survey ACR Guidelines: AP / lateral skull (+ Townes if suspicious of occipital fracture) Lateral cervical spine Lateral thoraco-lumbar spine.$

9 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

10 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

$Bone Scintigraphy When skeletal survey is negative, but clinical suspicion remains high Requires sedation and radiation Diagnosis of more subtle fractures that may$

11 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

$Computed Tomography (CT) Assessment of intracranial injuries, skull fractures, solid organ, hollow viscera injury$

12 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

13 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

14 Fractures High Specificity Lesions Classic Metaphyseal Lesions Rib Fractures (Post) Scapular Fractures Spinous Process Fractures Sternal Fractures Moderate Specificity Lesions Low Specificity lesions Multiple Fractures Fractures at different ages Epiphyseal Separation Vertebral body fractures and subluxations Skull Fractures Digital Fractures Subperiostal New bone formation Clavicular fractures Long bone fractures Linear skull fractures

$Metaphyseal Corner fracture$ of zone of provisional

15 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

16 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

17 Rib Fractures High specificity for abuse: PPI of Posteromedial rib # in < 3yo: 95%

$egg-shell fractures,$ $fractures, fractures$

18 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

$fracture in <1yo due to$

19 Long Bone Fractures Low specificity for Nonaccidental injury Femur fracture in <1yo due to abuse: estimated 39-93%

$Subperiosteal new bone formation 14-21 days Immature or soft callus, loss of fracture line definition >21 days Mature$

20 Healing & Dating of Fractures Time course Finding 4-10 days Resolution of soft tissue swelling days Subperiosteal new bone formation 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

21 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:

22 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

$rib fractures for non-accidental injury Repeat skeletal survey may be necessary Multidisciplinary team approach and communication with referring physician$

23 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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25 References 27. Conway JJ, Collins M, Tanz RR, et al. The role of bone scintigraphy in detecting child abuse. Semin Nucl Med 1993; 23(4): K. Darge et al. / European Journal of Radiology 68 (2008) Perez-Rossello. Whole Body MRI in suspected infant abuse AJR 2010;195: Kleinman PK, Marks SC, Blackbourne B. The metaphyseal lesion in abused infants: a radiologic-histopathologic study. AJR Am J Roentgenol. 1986;146: Helfer RE, Slovis TL, Black M. Injuries resulting when small children fall out of bed. Pediatrics. 1977;60: Lyons TJ, Oates RK. Falling out of bed: a relatively benign occurrence. Pediatrics. 1993;92: Nimityongskul P, Anderson LD. The likelihood of injuries when children fall out of bed. J Pediatr Orthop. 1987;7: Barsness KA, Cha ES, Bensard DD, Calkins CM, Partrick DA, Karrer FM, Strain JD. The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma. 2003;54: Merten DF, Kirks DR, Ruderman RJ. Occult humeral epiphyseal fracture in battered infants. Pediatr Radiol. 1981;10: Kemp AM, Dunstan F, Harrison S, et al: Patterns of skeletal fractures in child abuse; Systematic review. BMJ 2008; 337:a Kellogg ND. Evaluation of suspected child physical abuse. Pediatrics 2007; 119(6): Sato Y, Yuh WT, Smith WL, Alexander RC, Kao SC, Ellerbroek CJ. Head injury in child abuse: evaluation with MR imaging. Radiology 1989; 173(3): Chabrol B, Decarie JC, Fortin G. The role of cranial MRI in identifying patients suffering from child abuse and presenting with unexplained neurological findings. Child Abuse Negl 1999; 23(3): Duhaime AC, Christian CW, Rorke LB, Zimmerman RA. Nonaccidental head injury in infants--the "shaken-baby syndrome". N Engl J Med 1998; 338(25): Laskey AL, Holsti M, Runyan DK, Socolar RR. Occult head trauma in young suspected victims of physical abuse. J Pediatr 2004; 144(6): McKinney AM, Thompson LR, Truwit CL, Velders S, Karagulle A, Kiragu A. Unilateral hypoxic-ischemic injury in young children from abusive head trauma, lacking craniocervical vascular dissection or cord injury. Pediatr Radiol 2008; 38(2): Rex C, Kay PR. Features of femoral fractures in nonaccidental injury. J Pediatr Orthop. 2000;20: Scherl SA, Miller L, Lively N, Russinoff S, Sullivan CM, Tornetta P III. Accidental and nonaccidental femur fractures in children. Clin Orthop Relat Res. 2000; 376: Wellington P, Bennet GC. Fractures of the femur in childhood. Injury. 1987;18: O Connor JF, Cohen J. Dating fractures. In: Kleinman PK, ed. Diagnostic Imaging of Child Abuse. 2nd ed. St Louis, MO:Mosby Inc; 1998: Chapman S. The radiological dating of injuries. Arch Dis Child. 1992;67: Davies DV. Anatomy and physiology of diarthrodial joints. Ann Rheum Dis. 1945;5: Dwek JR. The periosteum: what is it, where is it, and what mimics it in its absence? Skeletal Radiol. 2010;39: Merten DF, Kirks DR, Ruderman RJ. Occult humeral epiphyseal fracture in battered infants. Pediatr Radiol. 1981;10:

Evidence Base for Child Abuse Fractures

Evidence Base for Child Abuse Fractures SPR Sunrise Session May 17, 2018 Megan B. Marine, MD, FAAP Assistant Professor of Clinical Radiology, Pediatric Division Co-Director, Pediatric Radiology Fellowship