More history: Seen by PCP yesterday because of vomiting and fussinesss. Called by ED today because Mom presents with same complaints. ED found nothing but got an abdominal x ray. ED now wants kid admitted for observation because kid seems really fussy and they can t find a reason. Bilateral rib fractures 2 on right and 1 on left In different stages of healing, with left fracture older than right fractures You suspect physical abuse 1
WHAT NOW? 2
GET A SKELETAL SURVEY 6 AP skull Right lateral skull Left lateral skull AP chest Right oblique ribs Left oblique ribs AP abdomen/pelvis AP right humerus Lateral right humerus AP left humerus Lateral left humerus AP right forearm Lateral right forearm AP left forearm Lateral left forearm PA right hand PA left hand AP right femur Lateral right femur AP left femur Lateral left femur AP right tibia/fibula Lateral right tibia AP left tibia/fibula Lateral left tibia/fibula AP right foot AP left foot Lateral C spine Lateral T L spine ACR Appropriateness Criteria Pediatric Topics Suspected physical abuse Urinary tract infection Vomiting in infants up to 3 months of age 3
What other imaging is needed? <24 months old, no neuro or visceral injuries suspected 9 Skeletal survey 6 MRI head without contrast 5 CT head without contrast 4 Whole body bone scan 2 MRI head with(out) contrast 1 CT head with contrast 1 CT head with(out) contrast >24 months old, no neuro or visceral injuries suspected 9 X ray area of interest 6 CT head without contrast 5 Skeletal survey 5 MRI head without contrast 4 Whole body bone scan 2 MRI head with(out) contrast 1 CT head with contrast 1 CT head with(out) contrast Adapted from Reference 6 What about the child with more complex injuries, with one or more of the following? Neurologic signs or symptoms Apnea Complex skull fracture Other fractures Injuries highly suspicious of child abuse NO SUSPECTED VISCERAL INJURIES 9 X ray skeletal survey 9 CT head without contrast 8 MRI head without contrast 8 MRI cervical spine without contrast 5 MRI complete spine without contrast 5 Whole body bone scan 3 MRI head with(out) contrast 2 MRI cervical spine with(out) contrast 2 MRI complete spine with(out) contrast 1 CT head with contrast 1 CT head with(out) contrast Adapted from Reference 6 4
What if child has suspected injury in thorax, abdomen or pelvis? Abdominal skin bruising Abdominal distention Abdominal tenderness Elevated liver or pancreatic enzymes 9 X ray skeletal survey 9 CT abdomen/pelvis with IV contrast 6 CT chest with contrast 6 CT head without contrast 6 MRI head without contrast 4 Whole body bone scan 3 CT chest without contrast 2 MRI head with(out) contrast 2 CT abdomen/pelvis without contrast 1 CT head with contrast 1 CT head with(out) contrast Adapted from Reference 6 Cases of abuse may not be straightforward ACR Appropriateness Criteria are very helpful in determining what studies are needed Don t forget to consult with your friendly neighborhood pediatric radiologist If possible, consult with a child abuse pediatrician 5
Nonaccidental Trauma (NAT) 1 in 10 ALTE/BRUE If you don t suspect it, you will miss it TEN 4 Bruising of torso, ears, or neck in kids under 4 y.o. Any bruising under 4 m.o. Pierce MC, Kaczor K, Aldridge S, O'Flynn J, Lorenz DJ. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2010;125(1):67 74. Know how to refer a kid to CPS before you have to NAT: X Rays Look carefully at entire x ray If there is a rib fracture/suspicion of rib fracture within lower chest on an abdominal x ray, at a minimum, you will need chest, 2 views also bilateral oblique views of ribs 6
NONACCIDENTAL TRAUMA Rib fractures are common Can be difficult to see on x rays unless callus has formed 11 WEEK OLD MALE Posterior rib fractures, near costovertebral junction, are especially characteristic 7
NONACCIDENTAL TRAUMA Rib Fractures Fractures can occur anywhere on rib arc, from costochondral junction to costovertebral articulation NONACCIDENTAL TRAUMA Rib fractures are unusual unless child has experienced major thoracic trauma Typically due to AP thoracic compression 8
NONACCIDENTAL TRAUMA Rib Fractures May be single, multiple, unilateral, or bilateral Should raise suspicion of NAT NONACCIDENTAL TRAUMA Coexistence of two or more fractures: Moderately specific sign of NAT, especially if remote from each other and particularly if in different phases of healing 9
Skeletal Survey/Pediatric Trauma Survey 29 images! Do we need all 29 images? Typically, yes, unless very recent (within last day or two) image(s) of good quality Entire/Most of Extremity on 1 Image? Is it okay to try to get an entire extremity on one image? Usually not, depends on the patient May not be able to detect a very subtle acute or healing fracture 10
Often important DATING of FRACTURES Often discussed Often unsatisfying DATING FRACTURES* Timetable of Radiologic Changes in Children s Fractures** CATEGORY EARLY PEAK LATE 1. SPNBF 6 10 days 10 14 days 14 21 days 2. Loss of fracture line definition 10 14 days 14 21 days 3. Soft callus 9 15 days 15 21 days 4. Hard callus 14 21 days 21 42 days 42 90 days *Kleinman, P.K., ed. Diagnostic Imaging of Child Abuse, 3 rd edition. Cambridge University, Cambridge, UK, 2015. **Repetitive injuries may prolong all categories 11
3 ½ month old 12
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What if subperiosteal new bone formation (SPNBF) is not symmetric, or is >2mm in thickness? Healing injury! Pediatric Trauma Survey 26 month old male 16
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WHAT HAVE YOU SEEN? Burns 22
Frequency of Skeletal Injuries in Children with Inflicted Burns Kimberly E Fagen, Eglal Shalaby Rana, Allison M. Jackson Pediatric Radiology (2015) 45:396 401 nearly one third of those children with inflicted burns had associated skeletal injuries, most commonly healing rib fractures. Thus young children with concern for nonaccidental burns should undergo a skeletal survey. 23
So when there is concern for NAT, you need to consider getting a skeletal survey 24
What did you see? 25
Now what? Repeat after 10 14 days! 26
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What do you see? 1 st study 2 nd study, 16 days later 28
Follow up Skeletal Survey Ribs looked normal on 1 st Skeletal Survey no evidence of fracture then Obvious healing rib fractures on follow up skeletal survey When there is concern for NAT, follow up Skeletal Survey is mandatory 7 Month old Ex Premie Shortness of Breath 29
What do you see? 30
Bilateral healing rib fractures! 4 month old, transferred from OSH with ALTE 31
4 month old 4 month old, 3 days later, WOB 32
Later on same day What do you see? 33
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Healing left rib fractures, consistent with NAT Next Patient He seems different 35