Interesting Case

Chris McCrossin R1

Emergency Medicine

Initial Presentation• Friday Night: 4 month old girl Referred from

family physician because of a 3 day history of persistent vomiting and grunting

• The story: Dad was coming back from grocery shopping and put baby and car seat on the kitchen table. Turned around to start putting groceries away when baby rolled out of the car seat and hit head on the hardwood floor (fall of about 3.5 feet)

More History• Since the fall:

» Not sleeping well

» Persistently irritable with only short intervals where she wasn’t crying. Not sleeping well

» Persistent vomiting (had seven episodes in a 1/2 hour time span prior to me seeing her)

» Persistent grunting respirations

» Not taking to the breast (only taking small amounts of formula)

» Ros: No fevers, No diarrhea, No cough, No signs of respiratory distress, No cyanosis

• PMHx: 1 prior ear infection

Physical Examination• Vitals: 36.8, P 164, RR 56, 107/63, SaO2 100% r/a

• HEENT:» TM’s N, Throat N, no lymphadenopathy, no conjunctivitis, no

external signs of head trauma• CVS:

» S1, S2, no murmur, regular rhythm• Resp:

» Persistent grunting with respirations when not crying, high pitched cry, no cyanosis, no adventitious sounds

• Abd:» Difficult to assess because crying every time she is laid down

• Neuro:» Alert, easily irritated, crying throughout most of the

assessment, moving all 4 extremities equally, pupils reactive but intermittently asymmetrical, full fontanelle (but crying), reflexes symmetric, fundi appeared normal

• Derm:» No rash, no bruises

Prior Work-up• Had been seen by doc in their home

town. Skeletal survey had been done and was reported as normal. Sent to ACH for further assessment of “grunting, vomiting, irritability, and decreased feeding”.

Differential Diagnosis for this upset baby

• Infection (pneumonia, UTI, Meningitis)

• Head Trauma• Child Abuse• Political turmoil south of

the border?• Other (hair tourniquet,

corneal abrasion)

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Why do babies grunt?• FOUR REASONS:

• Pain• Respiratory infection• Neurological injury• Sepsis (acid/base disturbance)

Our Work-up• CT Scan

• Completely normal

• Labs• No evidence of UTI, CBC and lytes N

• CXR:

Chest Xray

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Fractures Associated with Child Abuse

• High Specificity– Posterior Rib Fractures– Metaphyseal lesions

• bucket handle• Corner fracture

– Spinous process fractures

– Sternal fractures– Multiple fractures in

stages of healing– Occipital Impression

fractures

• Low Specificity– Epipheseal

Separations– Vertebral body

fractures– Complex skull

fractures– Digit fractures

Specificity of Rib Fractures• Rib fractures and their

association with child abuse is inversely proportional to age

• In Children < 3 they are highly specific for abuse

• Numerical value for specificity is a very difficult number to find in the literature

• Paper by Williams and Connolly in Arch Dis Child 2004 May: 89(5) reviews all studies relevant to answering this question

Other fractures

Corner Fractures• First described by

Caffey who noted an association of these fractures with subdural hematomas

Bucket Handle Fractures• Avulsed bone

fragment• Common sites:

– Tibia– Distal femora– Proximal humeri– Frequently bilateral

Diaphyseal Fractures• Highly suspect of

child abuse in children not yet ambulatory

• Suspicious in ambulatory children with history inconsistent of child abuse

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Differential Diagnosis for Multiple/ Unusual Fractures

Osteogenesis Imperfecta• May present with multiple

fractures and bruising• Collagen disorder• Although genetic, wide

phenotypic variability and mosaicism, spontaneous mutations common

• Signs/Symptoms– Poor growth– Blue Sclera– Easy Bruising– Limb Deformities/scoliosis– Demineralized Bones– Hearing impairment

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Preterm Birth• Bone Density may not normalize until first year

of life• Osteopenia common complication • Often presents between 6-12 weeks of age• Complicated because preterm infants at

increased risk of abuse

Metaphyseal Dysplasia• Rare genetic

disorder• Can resemble old

corner fractures

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Osteomyelitis• Infants can present with multiple lesions at the

metaphyses of long bones

• May initially resemble the classical metaphyseal lesions found in abused children

• Expect fever, increased WBC, increased ESR

How good are the radiological tests at identifying fractures of child abuse?

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Radiographic Studies in Suspected Child Abuse Cases

• Systematic Review of literature on radiographic techniques used to diagnose child abuse

• Kemp et al; Clinical Radiology (2006) 61, 723-736.

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Skeletal Survey Guidelines

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References• Kemp et al. Which radiological investigations should

be performed to identify fractures in suspected child abuse? Clinical Radiology. 2006; 61:723-736.

• Jenny et al. Evaluating infants and young children with multiple fractures. Pediatrics. 2006; 118:1299-1303.

• William et al. In children undergoing chest radiography what is the specificity of rib fractures for non-accidental injury? Archives of Diseases in Childhood. 2004; 89(5): 490-492

• Nelson Textbook of Pediatrics (online at MD Consult)• The Radiology Assistant.

http://www.radiologyassistant.nl/en/42023a885587e

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