Diagnosing Child Abuse: the Role of the...

Diagnosing Child Abuse: the Diagnosing Child Abuse: the Role of the RadiologistRole of the Radiologist

Shireen F. Shireen F. CamaCama Gillian Lieberman, M.D.Gillian Lieberman, M.D.

March 2008March 2008

http://www.bidmc.harvard.edu/

Child Abuse: The EpidemicChild Abuse: The Epidemic

2004: 152,250 children/adolescents confirmed 2004: 152,250 children/adolescents confirmed victims of physical abuse in the United Statesvictims of physical abuse in the United States

Child abuse is a medical/public health issue: Child abuse is a medical/public health issue: vvictims of child abuse more likely to develop long ictims of child abuse more likely to develop long term mental, physical, emotional disabilitiesterm mental, physical, emotional disabilities

Mandated reporting of suspected child abuseMandated reporting of suspected child abuse

Radiologists often the first to suspect/diagnose Radiologists often the first to suspect/diagnose child abusechild abuse

Kellogg, N and Committee on Child Abuse and Neglect. Kellogg, N and Committee on Child Abuse and Neglect. ““Evaluation of Suspected Child Physical Abuse.Evaluation of Suspected Child Physical Abuse.””

PediatricsPediatrics

Vol 119 No. 6 June 2007 pp 1232Vol 119 No. 6 June 2007 pp 1232--

12411241

Our Patient: ASOur Patient: AS

3 month old female brought to CHB from 3 month old female brought to CHB from OSH for new onset seizures and lethargy OSH for new onset seizures and lethargy

FatherFather’’s story: AS left unrestrained in s story: AS left unrestrained in babychair on floor. Father returns after 2 babychair on floor. Father returns after 2 minutes to find baby being dragged on the minutes to find baby being dragged on the floor by 2floor by 2--yearyear--old brother. AS started old brother. AS started seizing and was brought to ED.seizing and was brought to ED.

CT as part of seizure workupCT as part of seizure workup

Patient AS: Parietal Bone Patient AS: Parietal Bone FractureFracture

Images courtesy of Dr. Paul Kleinman & Dr. Jay Pahade, Children's Hospital Boston

Axial C- CT, Bone Window

Patient AS: Suture DiastasisPatient AS: Suture Diastasis



Patient AS: Soft Tissue Patient AS: Soft Tissue HematomaHematoma



Patient AS: Subdural HematomaPatient AS: Subdural Hematoma

Images courtesy of Dr. Paul Kleinman & Dr. Jay Pahade, Children's Hospital Boston Axial C- CT, Brain Window

Patient AS: Patient AS: Left Temporoparietal Subdural Hematoma


Patient AS: Loss of Gray/White Patient AS: Loss of Gray/White Matter DifferentiationMatter Differentiation


Patient AS: Effacement of Left Patient AS: Effacement of Left Lateral VentricleLateral Ventricle


Patient AS: Sulcal EffacementPatient AS: Sulcal Effacement


While CWhile C-- CT is the test of CT is the test of choice for detecting acute choice for detecting acute

intracranial hemorrhage, MRI intracranial hemorrhage, MRI is more sensitive for detecting is more sensitive for detecting

subacute and chronic subacute and chronic hemorrhage.hemorrhage.

Patient AS: Petechial Patient AS: Petechial HemorrhageHemorrhage


Axial MRI Gradient Echo

NonNon--Accidental Head Injury Accidental Head Injury (NAHI)(NAHI)

Head trauma is the leading cause of child abuse Head trauma is the leading cause of child abuse fatalitiesfatalities

Injury by direct contact and/or by indirect forces Injury by direct contact and/or by indirect forces of acceleration/decelerationof acceleration/deceleration

Constellation of injuries include: retinal Constellation of injuries include: retinal hemorrhages, subdural hematoma (SDH), hemorrhages, subdural hematoma (SDH), intracerebral contusions, diffuse cerebral edemaintracerebral contusions, diffuse cerebral edema

Variety of presentations: vomiting, lethargy, Variety of presentations: vomiting, lethargy, seizures, respiratory distress, mild changes in seizures, respiratory distress, mild changes in mental status, asymptomatic mental status, asymptomatic

The Skeletal Survey Performed The Skeletal Survey Performed to Evaluate for Fractures in to Evaluate for Fractures in

Suspected Child AbuseSuspected Child Abuse

Skull: AP and lateralSkull: AP and lateral

Spine: AP and lateralSpine: AP and lateral

Chest: AP, right posterior oblique, left posterior obliqueChest: AP, right posterior oblique, left posterior oblique

Pelvis and hips: APPelvis and hips: AP

Lower extremities: AP and frog lateralLower extremities: AP and frog lateral

Upper extremities (shoulder through wrist): APUpper extremities (shoulder through wrist): AP

Hands: PAHands: PA

Feet: APFeet: AP

Sternum: lateral Sternum: lateral

Boal, D. Child Abuse. Boal, D. Child Abuse. CaffeyCaffey’’s Pediatric Diagnostic Imaging, 10th ed.s Pediatric Diagnostic Imaging, 10th ed.

Ed Kuhn, J et al. Vol 2. Philadelphia: Mosby, 2004: 2304-2318.

Fractures Specific for Child Fractures Specific for Child Abuse: Low SpecificityAbuse: Low Specificity

Subperiosteal new bone formation

Clavicular fractures

Long bone shaft fractures

Linear skull fractures

Fractures Specific for Child Fractures Specific for Child Abuse: Moderate SpecificityAbuse: Moderate Specificity

Multiple fractures, especially bilateral

Fractures of different ages

Epiphyseal separations

Vertebral body fractures and subluxations

Digital fractures

Complex skull fractures

Fractures Specific for Child Fractures Specific for Child Abuse: High SpecificityAbuse: High Specificity

Classic metaphyseal lesions

Rib fractures, especially posterior

Scapular fractures (including acromion)

Spinous process fractures

Sternal fractures

The Classic Metaphyseal Lesion The Classic Metaphyseal Lesion (CML)(CML)

Most common in children less than 2 years of age

Results from shaking of extremities or chest

Most often in distal femur, proximal tibia, distal tibia, proximal humerus

Reflects shearing injury extending through primary spongiosa of the metaphysis

Kleinman PK, Marks SC Jr. “Relationship of the subperiosteal bone collar to metaphyseal lesions in abused infants.”

J Bone Joint Surg Am 1995; 77: 1471-1476.

The Classic Metaphyseal The Classic Metaphyseal Fracture (CML): Corner FractureFracture (CML): Corner Fracture

•Reflects shearing injury extending through primary spongiosa of the metaphysis

•Most often in distal femur, proximal tibia, distal tibia, proximal humerus

•Results from shaking of extremities or chest

•Most common in children less than 2 years of age



rad.usuhs.mil/rad/home/peds/bucketarrow.jpg

The Classic Metaphyseal The Classic Metaphyseal Fracture (CML): Bucket Handle Fracture (CML): Bucket Handle

FractureFracture



<http://sprojects.mmi.mcgill.ca/icmcradiology/index.aspx>.

Patient AS: Healing Corner CML Patient AS: Healing Corner CML of Proximal Tibiaof Proximal Tibia


Patient AS: Transverse Fracture Patient AS: Transverse Fracture of Left Acromionof Left Acromion


Patient AS: Callus Formation Patient AS: Callus Formation


Patient AS: Healing Fractures of Patient AS: Healing Fractures of Posterior Ribs on CXRPosterior Ribs on CXR


Skeletal Survey vs. ScintigraphySkeletal Survey vs. ScintigraphySkeletal survey is more sensitive for detection of...

healed/healing injuries

skull fractures, spinal fracture and scapular fracture

Better able to evaluate type of lesion

Scintigraphy is more sensitive for detection of…

Occult skeletal injuries in early stages

Rib fractures, acute nondisplaced long bone fractures, subperiosteal hemorrhage

Soft tissue injuries

Will not pick up healed fractures

More expensive and difficult to interpret

Higher radiation exposure

Often requires sedation of child patientMandelstam, et. al. Arch Dis Child 2003;88:387–390

Recommendation: Bone Scintigraphy used as Adjunct to

Skeletal Survey

Patient AS: Increased uptake on Patient AS: Increased uptake on FF--18 Bone Scintigraphy18 Bone Scintigraphy

L 8th Rib

L Acromium

L Proximal Tibia

L Distal Femur


Fractures detected on plain film and scintigraphy.

Additional fractures detected on scintigraphy but not on plain film.

The previous slide illustrates the increased sensitivity of

scintigraphy over plain film for new fractures.

Patient AS: Additional Fracture Patient AS: Additional Fracture Detected at Two Week FollowDetected at Two Week Follow--UpUp

6th Rib

Images courtesy of Dr. Celeste Wilson, Children's Hospital Boston

Two week follow-up skeletal survey can reveal additional

fractures that may not have been apparent on prior plain film

because of the young age of the fracture.

Differential Diagnosis of Child Differential Diagnosis of Child AbuseAbuse

Skeletal LesionsSkeletal Lesions

Accidental Trauma

Birth Trauma

Normal Variants

Osteogenesis Imperfecta

Congenital Syphilis

Rickets

Congenital indifference to pain

Myelodysplasia

Osteomyelitis

Scurvy

Vitamin A intoxication

Caffe’s disease

Leukemia

Prostaglandin E therapy

Copper deficiency

Metaphyseal and spondylometaphyseal dysplasia

Menke’s syndrome

Methotrexate therapy

Subdural Hemorrhage or FluidSubdural Hemorrhage or Fluid

Accidental trauma

Birth trauma

Coagulopathies

Meningitis

Congenital brain metabolic abnormalities such as glutaric aciduria

Osteogenesis ImperfectaOsteogenesis Imperfecta

Rare: 1/20,000 births

Generalized disorder of type I collagen affecting bone, ligaments, skin, sclera, dentin

Consider OI if:

abnormal bone fragility with osteoporosis

Wormian bones

Joint laxity

Abnormal skin texture

Blue sclera

Defective dentition (dentinogenesis imperfecta)

Hearing loss

Companion Patient 1: Companion Patient 1: Osteogenesis ImperfectaOsteogenesis Imperfecta

OsteopeniaOsteopenia

Multiple FracturesMultiple Fractures

Soft bone leading to Soft bone leading to multiple bowing multiple bowing deformitiesdeformities

http://www.adhb.govt.nz/newborn/TeachingResourc

es/Radiology/Skeletal.htm

OI vs. Child AbuseOI vs. Child AbuseCompanion Patient 1 with confirmed OI Patient AS

Osteopenic bone with anterior bowing deformity

Normal bone with CML

Patient AS: Building a Case for Patient AS: Building a Case for Child AbuseChild Abuse

High Index of Clinical SuspicionHigh Index of Clinical Suspicion

Story of accidental injury inconsistent with type and Story of accidental injury inconsistent with type and pattern of injuriespattern of injuries

Gathering the EvidenceGathering the Evidence

Rule out metabolic causes Rule out metabolic causes

Several radiographic findings highly specific for child Several radiographic findings highly specific for child abuseabuse

Protect the childProtect the child

DSS involvementDSS involvement

Temporary custody till trialTemporary custody till trial

Patient AS: Fractures IncurredPatient AS: Fractures IncurredHigh Specificity

•Classic metaphyseal lesions

•Rib fractures, especially posterior

•Scapular fractures (including acromion)•Spinous process fractures

•Sternal fractures

Moderate Specificity

•Multiple fractures, especially bilateral

•Fractures of different ages•Epiphyseal separations

•Vertebral body fractures and subluxations

•Digital fractures

•Complex skull fracturesCommon but Low Specificity

•Subperiosteal new bone formation

•Clavicular fractures

•Long bone shaft fractures

•Linear skull fractures

AcknowledgementsAcknowledgements

Dr. Paul KleinmanDr. Paul Kleinman

Dr. Gillian LiebermanDr. Gillian Lieberman

Dr. Jay PahadeDr. Jay Pahade

Dr. Aarti SekharDr. Aarti Sekhar

Dr. Celeste WilsonDr. Celeste Wilson

ReferencesReferences

Ablin, D et al. Differentiation of Child Abuse from OsteogenesisAblin, D et al. Differentiation of Child Abuse from Osteogenesis Imperfecta. Imperfecta. Amer J Amer J Roentgen Roentgen 1990; 154(5): 10351990; 154(5): 1035--1046.1046.

Boal, D. Child Abuse. Boal, D. Child Abuse. CaffeyCaffey’’s Pediatric Diagnostic Imaging, 10s Pediatric Diagnostic Imaging, 10thth ed.ed. Ed Kuhn, J et al. Vol 2. Philadelphia: Mosby, 2004: 2304-2318.

Gruskin KD, Schutzman SA. Head trauma in children younger than 2Gruskin KD, Schutzman SA. Head trauma in children younger than 2 years: are there years: are there predictors for complications. predictors for complications. Arch Pediatr Adolesc Med.Arch Pediatr Adolesc Med. 1999;153 :15 1999;153 :15 ––20.20.

Kellogg, N and Committee on Child Abuse and Neglect. Kellogg, N and Committee on Child Abuse and Neglect. ““Evaluation of Suspected Evaluation of Suspected Child Physical Abuse.Child Physical Abuse.”” PediatricsPediatrics Vol 119 No. 6 June 2007 pp 1232Vol 119 No. 6 June 2007 pp 1232--1241.1241.

Kleinman PK, Marks SC Jr. “Relationship of the subperiosteal bone collar to metaphyseal lesions in abused infants.” J Bone Joint Surg Am 1995; 77: 1471-1476.

Kleinman PK. Diagnostic Imaging of Child Abuse, 2nd Ed. St. Lewis: Mosby, 1998.

Mandelstam, SA et al. Complementary use of radiological skeletal survey and bone scintigraphy in detection of bony injuries in suspected child abuse. Arch Dis Child 2003;88:387–390.

Skeletal Radiographs. Newborn Services. 21 Nov 2007. Aukland District Health Board. 19 Mar 2008. http://www.adhb.govt.nz/newborn/TeachingResources/Radiology/Skeletal.htm.

Stoodley, N. “Neuroimaging in non-accidental head injury: if, when, why and how.” Clinical Radiology 60, 2005: 22-30.

Trauma X or Child Abuse. ICM Radiology. 2006. McGill University Molson Medical Informatics. 20 Mar 2008. http://sprojects.mmi.mcgill.ca/icmcradiology/index.aspx .

http://www.adhb.govt.nz/newborn/TeachingResources/Radiology/Skeletal.htm

http://sprojects.mmi.mcgill.ca/icmcradiology/index.aspx

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