September 2005 Evaluation of a Pediatric Patient Percy Ballard, Harvard Medical School Year III
Our Little Man: 6mo old male transferred to Children s from hospital in the Philippines 3mo history of meningitis, seizures, developmental delay and subdural collections history of trauma: 2 foot fall from cradle
Acute CT Head Images: 3 months PTA PACS, Children s Hospital Boston
MRI Head Images: 2 days post- admission T1 T2 FLAIR PACS, Children s Hospital Boston DWI
Findings T2 Large bilateral subdural collections Rightward midline shift- mass effect Cystic encephalomalacia of cerebral hemispheres T1 PACS, Children s Hospital Boston
Tx- Neurosurgery: bilateral bur holes for drainage and aspiration Are we done? No!
Is There Possibility of Child Abuse? Duty of the radiologist Fractures that are specific for child abuse Common intracranial and visceral findings
Child Abuse: Intentional Wounding of a Child Includes physical, sexual, emotional abuse, neglect Most common in infants - 3yr olds. Radiologic imaging is legal documentation in cases of battering The law: radiologists are mandated to notify state authorities of any reasonable suspicion of abuse
Ddx of Suspected Child Abuse Accidental Trauma Birth trauma Osteogenesis imperfecta Infection (Congenital syphilis, osteomyelitis) Drug related bone changes
Duty of the Radiologist Skeletal survey Chest (AP) Abdomen & Pelvis (AP) Upper and Lower Extremities (AP) Hands (AP) and Feet (PA) Spine (AP & Lateral) Skull (AP& Lateral) Bone scan (optional- better for rib fractures than long bones)
Dr. Paul Kleinman s Approach to Fractures Divided into high, medium and low specificity for child abuse Highly specific for abuse Metaphyseal fractures ( bucket handle or corner ) Posterior rib fractures S fractures: scapular, spinous process, sternum
Examples of Abuse-Specific Fractures Companion Patient #2 Companion Patient #3 Companion Patient #4 Companion Patient #5 Metaphyseal fracture viewed laterally = corner fracture Corner fracture Spiral or Toddler s fracture (not specific for abuse) Metaphyseal fracture viewed en face = bucket handle fracture Posterior rib fracture http://www.aafp.org/afp/20 000515/3057.html http://www.amershamhealth.c om/medcyclopaedia/medical/v olume%20vii/metaphyseal %20FRACTURE.ASP http://rad.usuhs.mil/rad/home/ peds/abuse.html http://www.aafp.org/afp/20000515/3057.html
Fractures: Moderate and Low Specificity Fractures moderately specific for child abuse: Complex skull fractures Bilateral multiple fractures Salter-Harris fractures (epiphyseal separations) Vertebral body fractures Hand and foot fractures Low specificity: clavicle, linear skull fractures, long bones Companion Patient # 6 http://www.radiology.ucsf.edu/learning_ctr/docs/skeletal_trauma_child _Abuse.pdf Companion Patient #7 http://www.paaap.org/scan/course/06.html
Increase of Specificity is Based on History No explanation of injury Explanation of the injury changes History could not possibly account for radiographic findings
Common Intracranial Findings Subdural hemorrhages (most common) Companion Patient # 8 Companion Patient # 9 Subarachnoid w/ subdural hemorrhages (less common) http://pedsccm.wustl.edu/all- Net/english/other/images/head/ct/sub dhem.html http://www.netmedicine.co m/xray/ctscan/ct22.htm Companion Patient # 10 Companion Patient # 11 Epidural hematomas are rare,, occur w/ skull fractures http://www.chall.com/chall1/nl/imag es_091503/subarachnoid_hemorrh age2.jpg http://www.uth.tmc.edu/radiology /test/er_primer/skull_brain/brct/b rct15.html
Common Visceral Injuries Hematomas of duodenum and jejunum Companion Patient # 12 Pancreatitis http://bms.brown.edu/pedisurg/brown/ibimages/trauma/duodhemat.html Liver laceration Companion Patient # 13 Companion Patient # 14 Novelline, Robert A. 1998. Squire s Fundamentals of Radiology. 330, 308
Our Index Patient: CXR PACS, Children s Hospital Boston cm
Our Index Patient: Tc99 Bone Scan PACS, Children s Hospital Boston IM : 7
Findings Mature healing fractures of anterior right fifth, sixth, seventh ribs; left sixth and seventh ribs Skeletal survey suggestive of previous trauma Department of Social Services and Child Protection Team notified
Conclusions Duty as a physician Highly specific fractures: Metaphysis Posterior ribs S: Scapula, Sternum, Spinous process Less specific fractures Intracranial & abdominal injuries History affects index of suspicion
Many Thanks Jaques Tham,, MD Andrew Bennett, MD Larry Barbaras Pamela Lepkowski