Evidence Base for Child Abuse Fractures

Transcription

1 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 Indiana University School of Medicine Riley Hospital for Children, Indianapolis, IN

2 No Disclosures

3 Childhood Fractures Fractures are a common childhood injury Consider history, age and developmental stage of child, fracture type and associated mechanism, as well as identification of other injuries In infants and toddlers, physical abuse is the cause of 12-20% of fractures (1) Any fracture can be caused by child abuse

4 History HPI: Details important Children able should be interviewed apart and by a professional skilled in forensic interviewing One study showed caregivers either provided no history or a history of a low-energy event in cases of abuse, whereas 29% of caregivers of those with accidental injury provided a high-energy event (2) PMH, FH, PE and lab evaluation important in consideration of differential diagnosis

5 Age 80% of all fractures from abuse were seen in children under 18 months in large review (3) In children <1yo, 25% fractures caused by child abuse (4)

6 Developmental Stage Children who are not yet mobile are more likely to have fractures caused by abuse (1) In nonambulatory patients, physical abuse is the more likely cause of humeral and femoral fractures than those who are walking (2) % of fractures caused by abuse declines sharply after child begins to walk (1)

7 *High Specificity CMLs Rib Fractures Scapular Fractures Spinous Process Fractures Sternal Fractures Moderate Specificity Multiple Fractures Vertebral Body Fractures Epiphyseal Separations Fractures Differing Ages Digit Fractures Complex Skull Fractures Low Specificity Subperiosteal New Bone Formation Clavicle Fractures Long-bone Shaft Fractures Linear Skull Fractures *Highest Specificity in Infants (5)Flaherty EG, et al. Pediatrics 2014;133:

8 Classic Metaphyseal Lesion Planar fracture through primary spongiosa of the metaphysis (6) Corner or bucket handle appearance Most common in distal femur, proximal and distal tibia, and proximal humeri Acute fractures difficult to visualize and commonly heal without new subperiosteal bone formation or sclerosis (7) Heal quickly and undetectable in up to 4 weeks (7)

9 Classic Metaphyseal Lesion High specificity for physical abuse, particularly in the first year life (6,8) Mechanism: Torsional and tractional shearing strains applied across metaphysis as in pulling or twisting of an extremity (7) Supported by similar lesions in breech and armling obstetric deliveries (9) CMLs are the most common long bone fracture found in infants who die of inflicted injury (10)

10 Classic Metaphyseal Lesions

11 Classic Metaphyseal Lesions

12 Rib Fractures Rib fractures, particularly posterior rib fractures, in young children are highly specific for abuse (3,5) Positive predictive value of rib fractures for child abuse in children <3yo has been reported up to 95% (11) A child with multiple rib fractures has a 7 in 10 chance of having been abused (3)

13 Rib Fractures Mechanism: Most caused by anterior-posterior compression as in an infant who is held around the chest, squeezed, and shaken (12)

14 Posterior Rib Fractures

15 Posterior Rib Fractures

16 CT Chest in 70 do Female

17 CT Chest in 70 do Female

18 Long-bone Shaft Fractures Low specificity but important as the single long bone diaphyseal fracture is the most common fracture pattern identified in abused children (4) Fracture pattern itself cannot clearly distinguish between abuse and nonabuse (2) Important for injury mechanism described by caregiver to match the extent and type of load required (13)

19 Long Bone Fracture Mechanism Transverse fracture Bending load applied perpendicular to bone

20 Long Bone Fracture Mechanism Spiral fracture Torsion or twisting of bone along its long axis Accidental spiral femur fracture reported in stairway falls with specific circumstances (14)

21 Long Bone Fracture Mechanism Oblique fracture Bending and torsion combination Accidental oblique femur fracture reported in stationary activity center as in an Exersaucer (15)

22 Long Bone Fracture Mechanism Buckle/impacted fracture Axial loading along length of bone Accidental buckle femur fractures reported in short fall to the knee (13)

23 Femoral Shaft Fractures A child with a femoral fractures has a 1 in 3-4 chance of having been abused (3) Key discriminator is the motor developmental level of the child Femoral fractures resulting from abuse are more commonly seen in children who are not yet walking

24 Humeral Shaft Fractures In a child less than 18 mo, humeral shaft fractures have a high likelihood of abuse (3) Supracondylar fractures are more likely to have non-abusive causes Case reported of infant rolling from prone to supine while child s arm was extended causing a spiraloblique midshaft humerus fracture (16)

25 Skull Fractures Majority of linear skull fractures are not inflicted (17) A short fall from several feet onto a hard surface can cause a linear, nondiastatic skull fracture (18, 19) Complex or bilateral skull fractures are typical of NAT (5)

26 3D Skull Reformats: 6 mo female

27 3D Skull Reformats: 21 mo male

28 Skeletal Survey ACR imaging recommendations available by age and presentation Child <24mo with suspicion for abuse should have skeletal survey (20) Additional fractures are found in 10%, with higher rates in infants (21) 2 week follow up skeletal survey provides additional information in up to one third of patients (20)

29 When is a Fracture Suspicious for Child Abuse? No history of injury Mechanism provided not consistent with type of fracture Inconsistent or changing histories Fracture in nonambulatory child Fracture of high specificity for abuse Multiple fractures Fractures of different ages Other injuries suspicious for abuse Delay in seeking care for an injury (5) Flaherty EG, et al. Pediatrics 2014;133:

30 References 1. Leventhal JM, Martin KD, Asnes AG. Incidence of fractures attributable to abuse in young hospitalized children: results rom analysis of a US database. Pediatrics. 2008;122(3): Hui C, Joughin E, Goldstein S, et al. Femoral fractures in children younger than three years: the role of nonaccidental injury. J Pediatr Orthop. 2008;28(3): Kemp AM, Dunstan F, Harrison S, et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008;337:a Loder RT, Feinberg JR. Orthopaedic injuroes in children with nonaccidental trauma: demographics and incidence from the 2000 kids inpatient database. J Pediatr Orthop. 2008:28(6): Flaherty EG, Perez-Rossello JM, Levine MA et al. Evaluating children with fractures for child physical abuse. Pediatrics 2014;133: Kleinman PK. Diagnostic Imaging of Child Abuse. 2 nd ed. St. Louis, MO: Mosby; Kleinman PK. Problems in the diagnosis of metaphyseal fractures. Pediatr Radiol. 2008;38(suppl 3):S388-S Kleinman PK, Perez-Rossello JM, Newton AW, Feldman HA, Kleinmain PL. Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse. AJR AM J Roentgenol. 2011;197(4): Ekengren K, Bergdahl S, Ekstrom G. Birth injuries to the epiphyseal cartilage. Acta Radiol Diagn (stockh) 1978;19:

31 10. Kleinman PK, Marks SC, Jr, Richmond JM, et al. Inflicted skeletal injury: a postmortem radiologic-histopathologic study in 31 infants. AJR Am J Roentgenol. 1995;165(3): Barsness KA, Cha E-S, Bensard DD, et al. The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma. 2003;54(6): Kleinman PK, Marks, SC, Spevak MR, et al. Fractures of the rib heads in abused infants. Radiology 1992; Oct:185(1): Pierce MC, Bertocci G. Injury bio-mechanics and child abuse. Annu Rev Biomed Eng. 2008;10: Pierce MC, Bertocci GE, Janosky JE, et al. Femur fractures resulting from stair falls among children: an injury plausibility model. Pediatrics. 2005;115(6): Grant P, Mata MB, Tidwell M. Femur fractures in infants: a possible accidental etiology. Pedaitrics. 2001;108(4): Hymel KP, Jenny C. Abusive spiral fracture of the humerus: a videotaped exception. Arch Pediatr Adolesc Med. 1996;150(2): Wood JN, Christian CW, Adams, CM, et al. Skeletal surveys in infants with isolated skull fractures. Pediatrics. 2009;123(2)

32 18. Kleinman PK. The spectrum of nonaccidental injuries (child abuse) and its imitators. In: Hodler J, Zollikofer CL, Schulthess GK, eds. Musculoskeletal Disease Milan, Italy: Springer Italia; 2009: Laskey AL, Stump TE, Hicks RA, Smith JL. Yield of skeletal surveys in children,18months of age presenting with isolated skull fractures. J Pediatr. 2013;162(1): ACR appropriateness criteria: suspected physical child abuse. American College of Radiology Expert Panel on Pediatric Imaging: Sandra L Wooton-Gorges, Bruno P Soares, Adina L Alazraki, et. al. J Am Coll Radiol. 2017; 14: S338-S Duffy SO, Squires J, Fromkin JB et al. Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys. Pediatrics 2011;127:e47 e52

33 Thank You