Ashraf IJ, Faivus Ackley D, Razawich K, Botash A, Schafer M, Pekarsky A. Improving Follow-Up Skeletal Survey Completion in Children with Suspected Nonaccidental Trauma.. Pediatric Quality & Safety. 2022; 7 (3) : e567.
INTRODUCTION: The skeletal survey (SS) is used to evaluate and diagnose bone …
INTRODUCTION: The skeletal survey (SS) is used to evaluate and diagnose bone abnormalities, including fractures caused by child abuse. The American Academy of Pediatrics recommends initial SS for all children younger than 24 months old who are suspected victims of abuse and a follow-up skeletal survey (FUSS) 2 weeks later. The latter can further characterize abnormal or equivocal findings, detect ongoing trauma, or fractures too acute for visualization upon initial assessment. METHODS: Preintervention review at our hospital for FUSS completion of children younger than 36 months old yielded a low 40% average monthly completion rate. We reviewed charts of children who underwent SS during the study period for FUSS completion. There were several barriers to FUSS completion, including lack of provider knowledge regarding FUSS importance, lack of an order for FUSS before hospital discharge, absent chart documentation regarding FUSS decision, loss to follow-up, and parental refusal. Interventions targeting the barriers included provider education, protocolizing FUSS scheduling, standardizing documentation, and community pediatrician outreach. The goal was to increase the average monthly FUSS completion rate from 40% to 90% over 1 year. RESULTS: After interventions implementation, the average monthly FUSS completion rate rapidly increased from 40% to 80%. There was sustained improvement over the subsequent 12 months. CONCLUSIONS: Interventions were implemented sequentially, targeting barriers at various levels of workflow. Provider education was key and helped increase the reliability of intervention implementation. The most effective intervention was protocol change. This approach led to significant improvement in FUSS completion and sustained improvement.
Bradford R, Choudhary AK, Dias MS. Serial neuroimaging in infants with abusive head trauma: timing abusive injuries.. Journal of Neurosurgery. Pediatrics. 2013; 12 (2) : 110-9.
Keywords: Brain/diagnostic imaging/pathology, *Child Abuse, Craniocerebral Trauma/complications/*diagnosis/diagnostic imaging/epidemiology/*etiology, Diffusion Magnetic Resonance Imaging, Female, Hematoma, Subdural/diagnosis/etiology, Humans, Infant, Infant, Newbor
OBJECT: The appearance and evolution of neuroimaging abnormalities following …
OBJECT: The appearance and evolution of neuroimaging abnormalities following abusive head trauma (AHT) is important for establishing the time frame over which these injuries might have occurred. From a legal perspective this frames the timing of the abuse and therefore identifies and excludes potential perpetrators. A previous pilot study involving 33 infants with AHT helped to refine the timing of these injuries but was limited by its small sample size. In the present study, the authors analyzed a larger group of 210 cases involving infants with AHT to chronicle the first appearance and evolution of radiological (CT, MRI) abnormalities. METHODS: All children younger than 24 months admitted to the Penn State Hershey Medical Center with AHT over a 10-year period were identified from a medical record review; the time of injury was determined through an evaluation of the clinical records. All imaging studies were analyzed, and the appearance and evolution of abnormalities were chronicled on serial neuroimaging studies obtained in the days and weeks after injury. RESULTS: One hundred five infants with specific injury dates and available imaging studies were identified; a subset of 43 children additionally had documented times of injury. In infants with homogeneously hyperdense subdural hematomas (SDHs) on initial CT scans, the first hypodense component appeared within the SDH between 0.3 and 16 days after injury, and the last hyperdense subdural component disappeared between 2 and 40 days after injury. In infants with mixed-density SDHs on initial scans, the last hyperdense component disappeared between 1 and 181 days. Parenchymal hypodensities appeared on CT scans performed as early as 1.2 hours, and all were visible within 27 hours after the injury. Rebleeding into SDHs was documented in 17 cases (16%) and was always asymptomatic. Magnetic resonance imaging of the brain was performed in 49 infants. Among those with SDH, 5 patterns were observed. Patterns I and II reflected homogeneous SDH; Pattern I (T1 hyperintensity and T2/FLAIR hypointensity, "early subacute") more commonly appeared on scans performed earlier after injury compared with Pattern II (T1 hyperintensity and T2/FLAIR hyperintensity, "late subacute"), although there was considerable overlap. Patterns III and IV reflected heterogeneous SDH; Pattern III contained relatively equal mixtures having different intensities, whereas Pattern IV had fluid that was predominantly T1 hypointense and T2/FLAIR hyperintense. Again, Pattern III more commonly appeared on scans performed earlier after injury compared with Pattern IV, although there was significant overlap. CONCLUSIONS: These data extend the preliminary data reported by Dias and colleagues and provide a framework upon which injuries in AHT can be timed as well as the limitations on such timing estimates.
Choudhary AK, Servaes S, Slovis TL, Palusci VJ, Hedlund GL, Narang SK, Moreno JA, Dias MS, Christian CW, Nelson MD Jr, Silvera VM, Palasis S, Raissaki M, Rossi A, Offiah AC. Consensus statement on abusive head trauma in infants and young children.. Pediatric Radiology. 2018; 48 (8) : 1048-1065.
Keywords: Child, Child Abuse/*diagnosis/mortality, Child, Preschool, Consensus, Craniocerebral Trauma/*diagnosis/mortality, Hematoma, Subdural/diagnosis, Humans, Infant, Infant, Newborn, Retinal Hemorrhage/diagnosis, Rib Fractures/diagnosis, Societies, Medical,
Abusive head trauma (AHT) is the leading cause of fatal head injuries in …
Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.
Cosgrave L, Bowie S, Walker C, Bird H, Bastin S. Abusive head trauma in children: radiographs of the skull do not provide additional information in the diagnosis of skull fracture when multiplanar computed tomography with three-dimensional reconstructions is available.. Pediatric Radiology. 2022; 52 (5) : 924-931.
Keywords: Child, *Craniocerebral Trauma/diagnostic imaging, Humans, Imaging, Three-Dimensional/methods, Radiography, Retrospective Studies, Skull, *Skull Fractures/diagnostic imaging, Tomography, X-Ray Computed/methods
BACKGROUND: Some data suggest that CT is more accurate than skull radiographs …
BACKGROUND: Some data suggest that CT is more accurate than skull radiographs in diagnosing skull fractures in abusive head trauma. OBJECTIVES: We investigated whether multiplanar CT with three-dimensional (3-D) reconstructions alone is non-inferior to combination CT/skull radiography for the diagnosis of skull fracture in suspected physical abuse. MATERIALS AND METHODS: We identified children who had skull radiographs and concurrent multiplanar CT with 3-D reconstructions obtained during suspected physical abuse imaging between 2010 and 2019, and a fracture diagnosis in the formal report. We included all fracture cases and an equal number of randomly selected non-fracture controls in an anonymised dataset. This dataset was independently reviewed for skull fracture by two paediatric radiologists and one less-experienced trainee using either radiography alone, CT alone or CT/skull radiography. The primary outcome was discordance in diagnosis of skull fracture between CT alone and CT/skull radiography, with a result > 0.03 deemed to indicate inferiority of CT alone. The Fleiss kappa was used to assess interobserver agreement. RESULTS: We included 106 children, 53 with and 53 without skull fracture. A single case was discordant between CT alone and CT/skull radiography, resulting in discordance of 0.009, consistent with non-inferiority of CT alone. The sensitivity and specificity of CT alone and CT/skull radiography were 98% and 96-98%, respectively, whereas radiography alone was more inaccurate (81% sensitivity and 96% specificity). Interobserver agreement for all modalities was very high (kappa 0.86-0.95). CONCLUSION: Multiplanar CT with 3-D reconstructions alone is not inferior (and clinically equivalent) to CT/skull radiography for diagnosing skull fracture in suspected physical abuse imaging and was as accurate when reported by a less-experienced trainee. This suggests that skull radiography can be removed from suspected physical abuse imaging guidelines.
Darling SE, Done SL, Friedman SD, Feldman KW. Frequency of intrathoracic injuries in children younger than 3 years with rib fractures.. Pediatric Radiology. 2014; 44 (10) : 1230-6.
Keywords: Causality, Child Abuse/*diagnosis/*statistics & numerical data, Child, Preschool, Female, Humans, Incidence, Infant, Infant, Newborn, Male, Multiple Trauma/diagnostic imaging/*epidemiology, Radiography, Rib Fractures/diagnostic imaging/*epidemiology, Risk
BACKGROUND: Research documents that among children admitted to trauma intensive …
BACKGROUND: Research documents that among children admitted to trauma intensive care units the number of rib fractures sustained indicates the child's likelihood of having and severity of intrathoracic injury. This has been misused in court to argue that children with multiple rib fractures who lack intrathoracic injury have abnormal bone fragility rather than inflicted injury. OBJECTIVE: To determine frequency of intrathoracic injuries in children younger than 3 years with rib fractures in cases of child abuse and accidental trauma. MATERIALS AND METHODS: We conducted a retrospective review of rib fractures caused by documented abuse or accidents from 2003 to 2010 in children treated at Seattle Children's Hospital and Harborview Medical Center. A senior pediatric radiologist and radiology fellow independently reviewed the imaging. Children with bone demineralization were excluded. Descriptive and simple comparative statistics were used. RESULTS: Seventy-two percent (47/65) of infants and toddlers with rib fractures were abused. Abused children had more rib fractures than accidentally injured children (5.55 vs. 3.11, P = 0.012). However intrathoracic injuries as a whole (55.6% vs. 12.8%, P < 0.001) and individual types of intrathoracic injuries were more common with accidents. Rates of other thoracic cage injuries did not differ substantially (27.8% accidents vs. 12.8% abuse, P = 0.064). Intracranial and intra-abdominal injuries and skull fractures were equally frequent, but other extrathoracic fractures were more common with abuse (70.2% vs. 16.7%, P < 0.001). CONCLUSIONS: Abused infants and toddlers have fewer intrathoracic injuries but more rib fractures than accidentally injured peers. This likely reflects different injury mechanics. Lack of intrathoracic injuries in abused children with rib fractures does not imply bone fragility.
Flaherty EG, Perez-Rossello JM, Levine MA, Hennrikus WL, Christian CW, Crawford-Jakubiak JE, Leventhal JM, Lukefahr JL, Sege RD, MacMillan H, Nolan CM, Valley LA, Hurley TP, Cassady CI, Bulas DI, Cassese JA, Mehollin-Ray AR, Mercado-Deane MG, Milla SS, Thorne V, Sills IN, Blo. Evaluating children with fractures for child physical abuse. Pediatrics. 2014; 133 (2).
Keywords: Fractures
Fractures are common injuries caused by child abuse. Although the consequences …
Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures. Copyright \textcopyright 2014 by the American Academy of Pediatrics.
Henry MK, Bennett CE, Wood JN, Servaes S. Evaluation of the abdomen in the setting of suspected child abuse.. Pediatric Radiology. 2021; 51 (6) : 1044-1050.
Keywords: Abdomen, *Abdominal Injuries/diagnostic imaging, Child, *Child Abuse/diagnosis, *Fractures, Bone, Humans, Infant, Mass Screening
Abusive intra-abdominal injuries are less common than other types of injuries, …
Abusive intra-abdominal injuries are less common than other types of injuries, such as fractures and bruises, identified in victims of child physical abuse, but they can be deadly. No single abdominal injury is pathognomonic for abuse, but some types and constellations of intra-abdominal injuries are seen more frequently in abused children. Identification of intra-abdominal injuries can be important clinically or forensically. Injuries that do not significantly change clinical management can still elevate a clinician's level of concern for abuse and thereby influence subsequent decisions affecting child protection efforts. Abusive intra-abdominal injuries can be clinically occult, necessitating screening laboratory evaluations to inform decisions regarding imaging. Once detected, consideration of developmental abilities of the child, type and constellation of injuries, and the forces involved in any provided mechanism of trauma are necessary to inform assessments of plausibility of injury mechanisms and level of concern for abuse. Here we describe the clinical, laboratory and imaging evaluation of the abdomen in the setting of suspected child abuse.
Karmazyn B, Marine MB, Wanner MR, Cooper ML, Delaney LR, Jennings SG, Eckert GJ, Hibbard RA. Chest CT in the evaluation of child abuse - When is it useful?. Child Abuse & Neglect. 2022; 133 : 105823.
Keywords: Child, *Child Abuse/diagnosis, Female, Humans, Infant, Radiography, Retrospective Studies, *Rib Fractures/diagnostic imaging, Tomography, X-Ray Computed
BACKGROUND: Indications for chest CT in evaluation of child abuse are unknown. …
BACKGROUND: Indications for chest CT in evaluation of child abuse are unknown. OBJECTIVE: Determine which groups of children can best benefit from chest CT. PARTICIPANTS AND SETTING: 10-year (1/2010 to 12/2019) retrospective study of children <3 years who had chest CT within 3 days of the initial skeletal survey. METHODS: Demographic and clinical information were obtained from medical records. Two pediatric radiologists reviewed, independently and blinded to clinical information, anonymized rib X-rays (initial and follow up when available) and chest CT. Disagreements were resolved by a third pediatric radiologist. Agreement was evaluated using kappa statistics. Number and percentage of fractures were analyzed by negative binomial models and chi-square tests, respectively. RESULTS: 50 children (21 females) with average age of 9.7 months, 27 of whom had follow-up radiography. Agreement on initial and follow-up X-rays was substantial (k = 0.72) and perfect (k = 1.00), respectively, and almost perfect (k = 0.82) for CT scans. Chest CT demonstrated more fractures than X-ray, both initially (112 vs. 42, p < 0.0001) and at follow-up (93 vs. 49, p < 0.0001). Significantly more additional fractures were found at CT (11/13, 84.6 %) in patients with positive than in those with negative initial surveys (7/37, 18.9 %, p < 0.001). Ten initial surveys had only indeterminate fractures; four of them had fractures and six had no fractures on CT. Chest CT missed one patient (1/27, 3.7 %) with acute nondisplaced anterior rib fractures. CONCLUSION: Chest CT can be considered in children with negative skeletal survey and high clinical suspicion for child abuse, and when the diagnosis of rib fractures is indeterminate.
Kleinman PK, ed. Diagnostic Imaging of Child Abuse, 3rd Ed. Cambridge University Press, Cambridge, United Kingdom. 2015..
Kriss S, Thompson A, Bertocci G, Currie M, Martich V. Characteristics of rib fractures in young abused children.. Pediatric Radiology. 2020; 50 (5) : 726-733.
Keywords: Child Abuse/*diagnosis, Female, Humans, Infant, Infant, Newborn, Male, Radiography/*methods, Retrospective Studies, Rib Fractures/*diagnostic imaging, Ribs/diagnostic imaging
BACKGROUND: The presumed mechanism of rib fractures in abuse is violent …
BACKGROUND: The presumed mechanism of rib fractures in abuse is violent grasping of the torso causing anterior-posterior chest compression. We hypothesized an asymmetrical distribution of rib fractures in abused infants given the greater incidence of right-hand dominance within the general population. OBJECTIVE: The objective of this study was to characterize rib fractures in abused children, particularly sidedness; additionally, we evaluated the sidedness of other abusive skeletal fractures. MATERIALS AND METHODS: We reviewed medical records from abused children (0-18 months old) with rib fractures. We also retrospectively reviewed their radiographs to determine characteristics of rib fractures (number, side, rib region, level, acuity) and other skeletal fractures (number, side, location), as well as differences in the distribution of rib and other skeletal fractures. RESULTS: A total of 360 rib fractures were identified on 273 individual ribs involving 78 abused children. Sixty-three children (81%) had multiple rib fractures. There was a significantly greater number of left-side rib fractures (67%) than right-side fractures (P<0.001). Fractures were most often identified in the posterior and lateral regions and mid level of the ribcage (Ribs 5 through 8). Fifty-four percent of subjects had other skeletal fractures; these non-rib fractures were also predominantly on the left side (P=0.006). CONCLUSION: In our study of abused children, there was a higher incidence of rib fractures in the posterior, lateral and mid-level locations. Additionally, we found a predominance of left-side rib and other skeletal fractures. Further research is needed to understand whether factors such as perpetrator handedness are associated with these unequal distributions of fractures in abused children.
Lasiecka ZM, Pitot M, Chern BJ, Chern JJ, Kadom N. Skull Fracture Healing in Children Up to 36 Months - A Cohort Analysis.. Current Problems in Diagnostic Radiology. 2023; 52 (4) : 253-256.
Keywords: Infant, Newborn, Child, Humans, Infant, Child, Preschool, Retrospective Studies, *Fracture Healing, *Skull Fractures/diagnostic imaging/complications, Cohort Studies, Skull
During medicolegal proceedings in cases of suspected child abuse it is …
During medicolegal proceedings in cases of suspected child abuse it is sometimes argued that skull fractures could be sequelae from complications at birth or resulted from a prior witnessed accidental trauma that may have preceded the suspected abusive event. There is paucity of scientific evidence indicating timing for skull fracture healing in children up to 36 months old. Objective of this study was to assess the average time to imaging documentation of skull fracture healing in children up to 36 months old. We performed retrospective chart review and image analysis in children with documented skull fractures after trauma between May 2009 and December 2014, excluding any patients who underwent cranial procedures related to the head injury, patients with pre-existing CSF shunts, patients who were referred for child abuse evaluation, and patients who were admitted to the General Surgery service for multi-organ trauma.We analyzed 185 skull fractures: 82 fractures were not healed, 49 fractures were partially healed, and 54 fractures were healed on follow-up imaging. The mean time to imaging evidence of healing among patients with healed fractures was 108 days (3.6 months), the median was 112 days (3.7 months), the minimum was 22 days, and the maximum was 225 days (7.5 months). Chi-square analysis showed a significant relationship between the skull fracture healed status and presence of bleed (P = 0.001) and with fracture characteristics of displaced, depressed, or dehiscent (P= 0.009). There was no significant association with the age group (P= 0.32) nor with involvement of multiple cranial plates (P= 0.73). This information may be useful during medicolegal proceedings in patients with suspected abusive head trauma mechanism.
Lee JY, Coombs C, Clarke J, Berger R. Aspartate aminotransferase and alanine aminotransferase elevation in suspected physical abuse: Can the threshold to obtain an abdominal computed tomography be raised?. The Journal of Trauma and Acute Care Surgery. 2024; 97 (2) : 294-298.
Keywords: Humans, Retrospective Studies, *Alanine Transaminase/blood, Male, Female, Infant, Child, Preschool, *Tomography, X-Ray Computed/methods, *Aspartate Aminotransferases/blood, *Abdominal Injuries/diagnostic imaging/blood, *Child Abuse/diagnosis, Liver Functi
BACKGROUND: Identification of abdominal injury (AI) in children with concern …
BACKGROUND: Identification of abdominal injury (AI) in children with concern for physical abuse is important, as it can provide important medical and forensic information. Current recommendations are to obtain screening liver function tests (LFTs) in all children with suspected physical abuse and an abdominal computed tomography (CT) when the aspartate aminotransferase (AST) or alanine aminotransferase (ALT) is >80 IU/L. This threshold to obtain an abdominal CT is lower than general trauma guidelines, which use a cutoff of AST >200 IU/L or ALT >125 IU/L. METHODS: This was a retrospective review of children aged 0 to 60 months at a single pediatric tertiary care center who were evaluated for physical abuse and had AST or ALT >80 IU/L. Subjects were then stratified into two groups: midrange (AST ≤200 IU/L and ALT ≤125 IU/L) and high-range (AST >200 IU/L and/or ALT >125 IU/L) LFTs. RESULTS: Abdominal CTs were performed in 55% (131 of 237) of subjects, 38% (50 of 131) with midrange LFTs and 62% (81 of 131) with high-range LFTs. Abdominal injury was identified in 19.8% (26 of 131) of subjects. Subjects with AI were older than those without AI (mean [SD] age, 18.7 [12.5] vs. 11.6 [12.2] months; p = 0.009). The highest yield of abdominal CTs positive for AI was in the group with high-range LFTs with signs or symptoms of AI at 52.0% (13 of 25; 95% confidence interval, 31.3-72.2%). The negative predictive value of having midrange LFTs and no signs or symptoms of AI was 100% (95% confidence interval, 97.0-100%). CONCLUSION: Our data suggest that abdominal CT may not be necessary in children being evaluated for physical abuse who have AST ≤200 IU/L and ALT ≤125 IU/L and do not have signs or symptoms of AI. This could limit the number of abdominal CTs performed. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level IV.
Lindberg D, Makoroff K, Harper N, Laskey A, Bechtel K, Deye K, Shapiro R. Utility of hepatic transaminases to recognize abuse in children.. Pediatrics. 2009; 124 (2) : 509-16.
Keywords: Abdominal Injuries/*diagnosis/enzymology, Alanine Transaminase/*blood, Aspartate Aminotransferases/*blood, Child Abuse/*diagnosis, Child, Preschool, *Emergency Service, Hospital, Female, Humans, Infant, Infant, Newborn, Liver Function Tests/statistics & n
OBJECTIVE: Although experts recommend routine screening of hepatic …
OBJECTIVE: Although experts recommend routine screening of hepatic transaminases (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) in cases of potential child physical abuse, this practice is highly variable. Our objective was to determine the sensitivity and specificity of routine transaminase testing in young children who underwent consultation for physical abuse. PATIENTS AND METHODS: This was a prospective, multicenter, observational study of all children younger than 60 months referred for subspecialty evaluation of possible physical abuse. The child abuse team at each center recommended screening transaminases routinely as standard of care for all cases with a reasonable concern for physical abuse. Sensitivity and specificity for transaminases and clinical examination findings to detect identified abdominal injuries were determined, and receiver operating characteristic analysis was undertaken. RESULTS: Of 1676 consultations, 1272 (76%) patients underwent transaminase testing, and 54 (3.2% [95% confidence interval: 2.4-4.2]) had identified abdominal injuries. Area under the curve for the highest level of either transaminase was 0.85. Using a threshold level of 80 IU/L for either AST or ALT yielded a sensitivity of 77% and a specificity of 82% (positive likelihood ratio: 4.3; negative likelihood ratio: 0.3). Of injuries with elevated transaminase levels, 14 (26%) were clinically occult, lacking abdominal bruising, tenderness, and distention. Several clinical findings used to predict abdominal injury had high specificity but low sensitivity. CONCLUSIONS: In the population of children with concern for physical abuse, abdominal injury is an important cause of morbidity and mortality, but it is not so common as to warrant universal imaging. Abdominal imaging should be considered for potentially abused children when either the AST or ALT level is >80 IU/L or with abdominal bruising, distention, or tenderness.
Lindberg DM, Stence NV, Grubenhoff JA, Lewis T, Mirsky DM, Miller AL, O'Neill BR, Grice K, Mourani PM, Runyan DK. Feasibility and Accuracy of Fast MRI Versus CT for Traumatic Brain Injury in Young Children.. Pediatrics. 2019; 144 (4).
Keywords: Brain Injuries, Traumatic/*diagnostic imaging, Child, Preschool, Feasibility Studies, Female, Hematoma, Subdural/diagnostic imaging, Humans, Infant, Infant, Newborn, Intracranial Hemorrhages/diagnostic imaging, Magnetic Resonance Imaging/*methods/statisti
BACKGROUND: Computed tomography (CT) is commonly used for children when there …
BACKGROUND: Computed tomography (CT) is commonly used for children when there is concern for traumatic brain injury (TBI) and is a significant source of ionizing radiation. Our objective was to determine the feasibility and accuracy of fast MRI (motion-tolerant MRI sequences performed without sedation) in young children. METHODS: In this prospective cohort study, we attempted fast MRI in children <6 years old who had head CT performed and were seen in the emergency department of a single, level 1 pediatric trauma center. Fast MRI sequences included 3T axial and sagittal T2 single-shot turbo spin echo, axial T1 turbo field echo, axial fluid-attenuated inversion recovery, axial gradient echo, and axial diffusion-weighted single-shot turbo spin echo planar imaging. Feasibility was assessed by completion rate and imaging time. Fast MRI accuracy was measured against CT findings of TBI, including skull fracture, intracranial hemorrhage, or parenchymal injury. RESULTS: Among 299 participants, fast MRI was available and attempted in 225 (75%) and completed in 223 (99%). Median imaging time was 59 seconds (interquartile range 52-78) for CT and 365 seconds (interquartile range 340-392) for fast MRI. TBI was identified by CT in 111 (50%) participants, including 81 skull fractures, 27 subdural hematomas, 24 subarachnoid hemorrhages, and 35 other injuries. Fast MRI identified TBI in 103 of these (sensitivity 92.8%; 95% confidence interval 86.3-96.8), missing 6 participants with isolated skull fractures and 2 with subarachnoid hemorrhage. CONCLUSIONS: Fast MRI is feasible and accurate relative to CT in clinically stable children with concern for TBI.
Mankad K, Sidpra J, Mirsky DM, Oates AJ, Colleran GC, Lucato LT, Kan E, Kilborn T, Agrawal N, Teeuw AH, Kelly P, Zeitlin D, Carter J, Debelle GD, Berger RP, Christian CW, Lindberg DM, Raissaki M, Argyropoulou M, Adamsbaum C, Cain T, van Rijn RR, Silvera V. International Consensus Statement on the Radiological Screening of Contact Children in the Context of Suspected Child Physical Abuse.. Jama Pediatrics. 2023; 177 (5) : 526-533.
Keywords: Child, Humans, Infant, *Physical Abuse, *Child Abuse, Physical Examination, Radiography, Siblings
IMPORTANCE: Physical abuse is a common but preventable cause of long-term …
IMPORTANCE: Physical abuse is a common but preventable cause of long-term childhood morbidity and mortality. Despite the strong association between abuse in an index child and abuse in contact children, there is no guidance outlining how to screen the latter, significantly more vulnerable group, for abusive injuries. Consequently, the radiological assessment of contact children is often omitted, or variably performed, allowing occult injuries to go undetected and increasing the risk of further abuse. OBJECTIVE: To report an evidence-based and consensus-derived set of best practices for the radiological screening of contact children in the context of suspected child physical abuse. EVIDENCE REVIEW: This consensus statement is supported by a systematic review of the literature and the clinical opinion of an internationally recognized group of 26 experts. The modified Delphi consensus process comprised 3 meetings of the International Consensus Group on Contact Screening in Suspected Child Physical Abuse held between February and June 2021. FINDINGS: Contacts are defined as the asymptomatic siblings, cohabiting children, or children under the same care as an index child with suspected child physical abuse. All contact children should undergo a thorough physical examination and a history elicited prior to imaging. Contact children younger than 12 months should have neuroimaging, the preferred modality for which is magnetic resonance imaging, and skeletal survey. Contact children aged 12 to 24 months should undergo skeletal survey. No routine imaging is indicated in asymptomatic children older than 24 months. Follow-up skeletal survey with limited views should be performed if abnormal or equivocal at presentation. Contacts with positive findings should be investigated as an index child. CONCLUSIONS AND RELEVANCE: This Special Communication reports consensus recommendations for the radiological screening of contact children in the context of suspected child physical abuse, establishing a recognized baseline for the stringent evaluation of these at-risk children and providing clinicians with a more resilient platform from which to advocate for them.
Marine MB, Corea D, Steenburg SD, Wanner M, Eckert GJ, Jennings SG, Karmazyn B. Is the new ACR-SPR practice guideline for addition of oblique views of the ribs to the skeletal survey for child abuse justified?. Ajr. American Journal of Roentgenology. 2014; 202 (4) : 868-71.
Keywords: Child Abuse/*diagnosis, Female, Humans, Infant, Infant, Newborn, Male, *Practice Guidelines as Topic, Radiography, Thoracic/*standards, Rib Fractures/*diagnostic imaging, Ribs/*injuries, Sensitivity and Specificity, Specialty Boards, United States
OBJECTIVE: The purpose of our study was to determine whether adding oblique …
OBJECTIVE: The purpose of our study was to determine whether adding oblique bilateral rib radiography to the skeletal survey for child abuse significantly increases detection of the number of rib fractures. MATERIALS AND METHODS: We identified all patients under 2 years old who underwent a skeletal survey for suspected child abuse from January 2003 through July 2011 and who had at least one rib fracture. These patients were age-matched with control subjects without fractures. Two randomized radiographic series of the ribs were performed, one containing two views (anteroposterior and lateral) and another with four views (added right and left oblique). Three fellowship-trained radiologists (two in pediatrics and one in trauma) blinded to original reports independently evaluated the series using a Likert scale of 1 (no fracture) to 5 (definite fracture). We analyzed the following: sensitivity and specificity of the two-view series for detection of any rib fracture and for location (using the four-view series as the reference standard), interobserver variability, and confidence level. RESULTS: We identified 212 patients (106 with one or more fractures and 106 without). The sensitivity and specificity of the two-view series were 81% and 91%, respectively. Sensitivity and specificity for detection of posterior rib fractures were 74% and 92%, respectively. There was good agreement between observers for detection of rib fractures in both series (average kappa values of 0.70 and 0.78 for two-views and four-views, respectively). Confidence significantly increased for four-views. CONCLUSION: Adding bilateral oblique rib radiographs to the skeletal survey results in increased rib fracture detection and increased confidence of readers.
Meyer JS, Gunderman R, Coley BD, Bulas D, Garber M, Karmazyn B, Keller MS, Kulkarni AV, Milla SS, Myseros JS, Paidas C, Pizzutillo PD, Podberesky DJ, Prince JS, Ragheb J. ACR Appropriateness Criteria(®) on suspected physical abuse-child.. Journal of the American College of Radiology : Jacr. 2011; 8 (2) : 87-94.
Keywords: Child, Child Abuse/*classification/*prevention & control, Diagnostic Imaging/*standards, Expert Testimony/*standards, Forensic Medicine/*standards, Humans, Radiology/*standards, United States
The appropriate imaging for pediatric patients being evaluated for suspected …
The appropriate imaging for pediatric patients being evaluated for suspected physical abuse depends on the age of the child, the presence of neurologic signs and symptoms, evidence of thoracic or abdominopelvic injuries, and whether the injuries are discrepant with the clinical history. The clinical presentations reviewed consider these factors and provide evidence-based consensus recommendations by the ACR Appropriateness Criteria(®) Expert Panel on Pediatric Imaging.
Narang SK, Fingarson A, Lukefahr J. Abusive Head Trauma in Infants and Children.. Pediatrics. 2020; 145 (4).
Keywords: Biomechanical Phenomena, Child, Child Abuse/*diagnosis/prevention & control, Child, Preschool, Contusions/diagnosis/etiology, Craniocerebral Trauma/*diagnosis/etiology/prevention & control, Diagnosis, Differential, Humans, Infant, Mandatory Reporting,
Abusive head trauma (AHT) remains a significant cause of morbidity and …
Abusive head trauma (AHT) remains a significant cause of morbidity and mortality in the pediatric population, especially in young infants. In the past decade, advancements in research have refined medical understanding of the epidemiological, clinical, biomechanical, and pathologic factors comprising the diagnosis, thereby enhancing clinical detection of a challenging diagnostic entity. Failure to recognize AHT and respond appropriately at any step in the process, from medical diagnosis to child protection and legal decision-making, can place children at risk. The American Academy of Pediatrics revises the 2009 policy statement on AHT to incorporate the growing body of knowledge on the topic. Although this statement incorporates some of that growing body of knowledge, it is not a comprehensive exposition of the science. This statement aims to provide pediatric practitioners with general guidance on a complex subject. The Academy recommends that pediatric practitioners remain vigilant for the signs and symptoms of AHT, conduct thorough medical evaluations, consult with pediatric medical subspecialists when necessary, and embrace the challenges and need for strong advocacy on the subject.
Otjen JP, Menashe SJ, Romberg EK, Brown ECB, Iyer RS. Pearls and Pitfalls of Thoracic Manifestations of Abuse in Children.. Seminars in Ultrasound, Ct, and Mr. 2022; 43 (1) : 51-60.
Keywords: Child, *Child Abuse/diagnosis, Humans, Infant, *Rib Fractures/diagnostic imaging, United States
Child abuse is a broad term that includes, but is not limited to, physical or …
Child abuse is a broad term that includes, but is not limited to, physical or emotional harm, neglect, sexual abuse, and exploitation. In 2018 in the United States, there were nearly 700,000 victims of such maltreatment, of which 1700 children died. The majority of deaths occur in infants and toddlers under 3 years of age. While clinical signs and symptoms may raise suspicion for inflicted injury, such as bruising in young infants, imaging often plays a central role in identifying and characterizing nonaccidental trauma. The purpose of this article is to discuss the array of inflicted traumatic injuries to the thorax in children. Rib fractures are among the most common and telling features of physical abuse, especially in infants. The locations of such fractures and differences in appearance while healing will be presented, along with potential mimics and pitfalls. Less typical fractures seen in abuse will also be reviewed, including those of the sternum, clavicle, spine, and scapula. Finally, uncommon injuries to the lungs, heart and esophagus will also be considered.
Paine CW, Fakeye O, Christian CW, Wood JN. Prevalence of Abuse Among Young Children With Rib Fractures: A Systematic Review.. Pediatric Emergency Care. 2019; 35 (2) : 96-103.
Keywords: Child Abuse/*statistics & numerical data, Child, Preschool, Female, Humans, Infant, Male, Prevalence, Rib Fractures/*etiology, Sensitivity and Specificity
OBJECTIVES: We aimed to estimate the prevalence of abuse in young children …
OBJECTIVES: We aimed to estimate the prevalence of abuse in young children presenting with rib fractures and to identify demographic, injury, and presentation-related characteristics that affect the probability that rib fractures are secondary to abuse. METHODS: We searched PubMed/MEDLINE and CINAHL databases for articles published in English between January 1, 1990, and June 30, 2014 on rib fracture etiology in children 5 years or younger. Two reviewers independently extracted predefined data elements and assigned quality ratings to included studies. Study-specific abuse prevalences and the sensitivities, specificities, and positive and negative likelihood ratios of patients' demographic and clinical characteristics for abuse were calculated with 95% confidence intervals. RESULTS: Data for 1396 children 48 months or younger with rib fractures were abstracted from 10 articles. Among infants younger than 12 months, abuse prevalence ranged from 67% to 82%, whereas children 12 to 23 and 24 to 35 months old had study-specific abuse prevalences of 29% and 28%, respectively. Age younger than 12 months was the only characteristic significantly associated with increased likelihood of abuse across multiple studies. Rib fracture location was not associated with likelihood of abuse. The retrospective design of the included studies and variations in ascertainment of cases, inclusion/exclusion criteria, and child abuse assessments prevented further meta-analysis. CONCLUSIONS: Abuse is the most common cause of rib fractures in infants younger than 12 months. Prospective studies with standardized methods are needed to improve accuracy in determining abuse prevalence among children with rib fractures and characteristics associated with abusive rib fractures.
Palusci VJ, Nazer D, Greydanus DE, Merrick J. An Introduction to the Medical Evaluation of Child Maltreatment. Nova, Hauppauge, NY. 2024..
As educators as well as clinicians, we recognized the scarcity of specific …
As educators as well as clinicians, we recognized the scarcity of specific books designed to address the needs of the resident trainee in this important area of pediatric practice. The American Academy of Pediatrics (AAP) and others have published a number of texts on child abuse; but, this book specifically addresses the need for easily accessible materials outlining the medical approach to child abuse and neglect for pediatric and family medicine trainees as well as other professionals working with children. It is a collection of materials that covers a range of topics and serves as a repository for materials we have found helpful when teaching about child abuse and neglect. In addition, it provides information for more advanced students and trainees who want to learn more than can be learned during standard rotations and clinical experiences. Child abuse identification, treatment and prevention is the responsibility of us all, and our hope is that all practitioners will recognize their responsibility to use their unique skills to provide the best care and treatment possible for this important and vulnerable pediatric population.
Piteau SJ, Ward MG, Barrowman NJ, Plint AC. Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review.. Pediatrics. 2012; 130 (2) : 315-23.
Keywords: Brain Injuries/diagnosis/epidemiology, Child Abuse/*diagnosis/statistics & numerical data, Child, Preschool, Cohort Studies, Craniocerebral Trauma/*diagnosis/epidemiology, Cross-Sectional Studies, Diagnosis, Differential, Diagnostic Errors, Female, Hospit
BACKGROUND AND OBJECTIVE: To systematically review the literature to determine …
BACKGROUND AND OBJECTIVE: To systematically review the literature to determine which clinical and radiographic characteristics are associated with abusive head trauma (AHT) and nonabusive head trauma (nAHT) in children. METHODS: We searched MEDLINE, EMBASE, PubMed, conference proceedings, and reference lists to identify relevant studies. Two reviewers independently selected studies that compared clinical and/or radiographic characteristics including historical features, physical exam and imaging findings, and presenting signs or symptoms in hospitalized children ≤ 6 years old with AHT and nAHT. RESULTS: Twenty-four studies were included. Meta-analysis was complicated by inconsistencies in the reporting of characteristics and high statistical heterogeneity. Notwithstanding these limitations, there were 19 clinical and radiographic variables that could be meta-analyzed and odds ratios were determined for each variable. In examining only studies deemed to be high quality, we found that subdural hemorrhage(s), cerebral ischemia, retinal hemorrhage(s), skull fracture(s) plus intracranial injury, metaphyseal fracture(s), long bone fracture(s), rib fracture(s), seizure(s), apnea, and no adequate history given were significantly associated with AHT. Epidural hemorrhage(s), scalp swelling, and isolated skull fracture(s) were significantly associated with nAHT. Subarachnoid hemorrhage(s), diffuse axonal injury, cerebral edema, head and neck bruising, any bruising, and vomiting were not significantly associated with either type of trauma. CONCLUSIONS: Clinical and radiographic characteristics associated with AHT and nAHT were identified, despite limitations in the literature. This systematic review also highlights the need for consistent criteria in identifying and reporting clinical and radiographic characteristics associated with AHT and nAHT.
Abdoo DC, Puls HT, Hall M, Lindberg DM, Anderst J, Wood JN, Parikh K, Tashijan M, Sills MR. Racial and ethnic disparities in diagnostic imaging for child physical abuse.. Child Abuse & Neglect. 2024; 149 : 106648 Section on Radiology; Diagnostic Imaging of Child Abuse..
Keywords: Humans, Infant, Infant, Newborn, Black or African American, *Child Abuse/diagnosis, Hispanic or Latino, Physical Abuse, Radiography, Retrospective Studies, White, *White People
IMPORTANCE: Racial bias may affect occult injury testing decisions for children …
IMPORTANCE: Racial bias may affect occult injury testing decisions for children with concern for abuse. OBJECTIVES: To determine the association of race on occult injury testing decisions at children's hospitals. DESIGN: In this retrospective study, we measured disparities in: (1) the proportion of visits for which indicated diagnostic imaging studies for child abuse were obtained; (2) the proportion of positive tests. SETTING: The Pediatric Health Information System (PHIS) administrative database encompassing 49 tertiary children's hospitals during 2017-2019. PARTICIPANTS: We built three cohorts based on guidelines for diagnostic testing for child abuse: infants with traumatic brain injury (TBI; n = 1952), children <2 years old with extremity fracture (n = 20,842), and children <2 years old who received a skeletal survey (SS; n = 13,081). MAIN OUTCOMES AND MEASURES: For each group we measured: (1) the odds of receiving a specific guideline-recommended diagnostic imaging study; (2) among those with the indicated imaging study, the odds of an abuse-related injury diagnosis. We calculated both unadjusted and adjusted odds ratios (AOR) by race and ethnicity, adjusting for sex, age in months, payor, and hospital. RESULTS: In infants with TBI, the odds of receiving a SS did not differ by racial group. Among those with a SS, the odds of rib fracture were higher for non-Hispanic Black than Hispanic (AOR 2.05 (CI 1.31, 3.2)) and non-Hispanic White (AOR 1.57 (CI 1.11, 2.32)) patients. In children with extremity fractures, the odds of receiving a SS were higher for non-Hispanic Black than Hispanic and non-Hispanic White patients (AOR 1.97 (CI 1.74, 2.23)); (AOR 1.17 (CI 1.05, 1.31)), respectively, and lower for Hispanic than non-Hispanic White patients (AOR 0.59 (CI 0.53, 0.67)). Among those receiving a SS, the rate of rib fractures did not differ by race. In children with skeletal surveys, the odds of receiving neuroimaging did not differ by race. Among those with neuroimaging, the odds of a non-fracture, non-concussion TBI were lower in non-Hispanic Black than Hispanic patients (AOR 0.7 (CI 0.57, 0.86)) and were higher among Hispanic than non-Hispanic White patients (AOR 1.23 (CI 1.02, 1.47)). CONCLUSIONS AND RELEVANCE: We did not identify a consistent pattern of race-based disparities in occult injury testing when considering the concurrent yield for abuse-related injuries.
Boehnke M, Mirsky D, Stence N, Stanley RM, Lindberg DM. Occult head injury is common in children with concern for physical abuse.. Pediatric Radiology. 2018; 48 (8) : 1123-1129.
Keywords: Child Abuse/*diagnosis/statistics & numerical data, Craniocerebral Trauma/*diagnostic imaging/epidemiology, Female, Humans, Infant, Infant, Newborn, Magnetic Resonance Imaging, Male, Neuroimaging/*methods, Prevalence, Retrospective Studies, Risk Factors,
BACKGROUND: Studies evaluating small patient cohorts have found a high, but …
BACKGROUND: Studies evaluating small patient cohorts have found a high, but variable, rate of occult head injury in children <2 years old with concern for physical abuse. The American College of Radiology (ACR) recommends clinicians have a low threshold to obtain neuroimaging in these patients. OBJECTIVES: Our aim was to determine the prevalence of occult head injury in a large patient cohort with suspected physical abuse using similar selection criteria from previous studies. Additionally, we evaluated proposed risk factors for associations with occult head injury. MATERIALS AND METHODS: This was a retrospective, secondary analysis of data collected by an observational study of 20 U.S. child abuse teams that evaluated children who underwent subspecialty evaluation for concern of abuse. We evaluated children <2 years old and excluded those with abnormal mental status, bulging fontanelle, seizure, respiratory arrest, underlying neurological condition, focal neurological deficit or scalp injury. RESULTS: One thousand one hundred forty-three subjects met inclusion criteria and 62.5% (714) underwent neuroimaging with either head computed tomography or magnetic resonance imaging. We found an occult head injury prevalence of 19.7% (141). Subjects with emesis (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.8-6.8), macrocephaly (OR 8.5, 95% CI 3.7-20.2), and loss of consciousness (OR 5.1, 95% CI 1.2-22.9) had higher odds of occult head injury. CONCLUSION: Our results show a high prevalence of occult head injury in patients <2 years old with suspected physical abuse. Our data support the ACR recommendation that clinicians should have a low threshold to perform neuroimaging in patients <2 years of age.
Chen SY, Gao L, Imagawa KK, Roseman ER, Shin CE, Kim ES, Spurrier RG. Screening for Child Abuse in Children With Isolated Skull Fractures.. Pediatric Emergency Care. 2023; 39 (6) : 374-377.
Keywords: Child, Humans, Infant, *Skull Fractures/diagnosis/epidemiology, *Child Abuse/diagnosis, *Craniocerebral Trauma, Emergency Service, Hospital, Social Work, Retrospective Studies
OBJECTIVE: Head trauma is the most common cause of death from child abuse, and …
OBJECTIVE: Head trauma is the most common cause of death from child abuse, and each encounter for recurrent abuse is associated with greater morbidity. Isolated skull fractures (ISF) are often treated conservatively in the emergency department (ED). We determined patterns of physical abuse screening in a children's hospital ED for children with ISF. METHODS: A retrospective review was performed for children aged 3 years and younger who presented to the ED with ISF from January 1, 2015 to December 31, 2019. Children were stratified by age (<12 mo, ≥12 mo) and witnessed versus unwitnessed injury. Primary outcome was social work (SW) assessment to prescreen for abuse. Secondary outcomes were suspicion for abuse based on Child Protective Services (CPS) referral and subsequent ED encounters within 1 year. RESULTS: Sixty-six ISF patients were identified. Of unwitnessed injury patients aged younger than 12 months (n = 17/22), 88.2% (n = 15/17) underwent SW assessment and 47.1% (n = 8/17) required CPS referral. Of witnessed injury patients aged younger than 12 months (n = 23/44), 60.9% (n = 14/23) underwent SW assessment, with no CPS referrals. Overall, 18.2% (n = 4/22) unwitnessed and 20.5% (n = 9/44) witnessed injury patients returned to our ED: 2 were aged younger than 12 months and had recurrent trauma. CONCLUSIONS: To decrease risk of missed physical abuse, SW consultation should be considered for all ISF patients.
Christian CW, Crawford-Jakubiak JE, Flaherty EG, Leventhal JM, Lukefahr JL, Sege RD. The evaluation of suspected child physical abuse. Pediatrics. 2015; 135 (5) : e1337-e1354.
Child physical abuse is an important cause of pediatric morbidity and mortality …
Child physical abuse is an important cause of pediatric morbidity and mortality and is associated with major physical and mental health problems that can extend into adulthood. Pediatricians are in a unique position to identify and prevent child abuse, and this clinical report provides guidance to the practitioner regarding indicators and evaluation of suspected physical abuse of children. The role of the physician may include identifying abused children with suspicious injuries who present for care, reporting suspected abuse to the child protection agency for investigation, supporting families who are affected by child abuse, coordinating with other professionals and community agencies to provide immediate and long-term treatment to victimized children, providing court testimony when necessary, providing preventive care and anticipatory guidance in the office, and advocating for policies and programs that support families and protect vulnerable children.
Christian CW, Levin AV. The Eye Examination in the Evaluation of Child Abuse.. Pediatrics. 2018; 142 (2).
Keywords: Child, Child Abuse/*diagnosis/prevention & control, Craniocerebral Trauma/complications/diagnosis/prevention & control, *Diagnostic Techniques, Ophthalmological/standards, Eye Injuries/*diagnosis/*etiology/prevention & control, Humans, Physical Examinatio
Child abuse can cause injury to any part of the eye. The most common …
Child abuse can cause injury to any part of the eye. The most common manifestations are retinal hemorrhages (RHs) in infants and young children with abusive head trauma (AHT). Although RHs are an important indicator of possible AHT, they are also found in other conditions. Distinguishing the number, type, location, and pattern of RHs is important in evaluating a differential diagnosis. Eye trauma can be seen in cases of physical abuse or AHT and may prompt referral for ophthalmologic assessment. Physicians have a responsibility to consider abuse in the differential diagnosis of pediatric eye trauma. Identification and documentation of inflicted ocular trauma requires a thorough examination by an ophthalmologist, including indirect ophthalmoscopy, most optimally through a dilated pupil, especially for the evaluation of possible RHs. An eye examination is helpful in detecting abnormalities that can help identify a medical or traumatic etiology for previously well young children who experience unexpected and unexplained mental status changes with no obvious cause, children with head trauma that results in significant intracranial hemorrhage and brain injury, and children with unexplained death.
Duhaime AC, Christian CW. Abusive head trauma: evidence, obfuscation, and informed management.. Journal of Neurosurgery. Pediatrics. 2019; 24 (5) : 481-488.
Keywords: Brain Injuries, Traumatic/diagnosis/therapy, Child, Child Abuse/*diagnosis/legislation & jurisprudence, Child Protective Services, Child, Preschool, Craniocerebral Trauma/*diagnosis/therapy, Hematoma, Subdural, Intracranial/diagnosis/therapy, Humans, Infa
Abusive head trauma remains the major cause of serious head injury in infants …
Abusive head trauma remains the major cause of serious head injury in infants and young children. A great deal of research has been undertaken to inform the recognition, evaluation, differential diagnosis, management, and legal interventions when children present with findings suggestive of inflicted injury. This paper reviews the evolution of current practices and controversies, both with respect to medical management and to etiological determination of the variable constellations of signs, symptoms, and radiological findings that characterize young injured children presenting for neurosurgical care.
Wootton-Gorges SL, Soares BP, Alazraki AL, Anupindi SA, Blount JP, Booth TN, Dempsey ME, Falcone RA Jr, Hayes LL, Kulkarni AV, Partap S, Rigsby CK, Ryan ME, Safdar NM, Trout AT, Widmann RF, Karmazyn BK, Palasis S. ACR Appropriateness Criteria(®) Suspected Physical Abuse-Child.. Journal of the American College of Radiology : Jacr. 2017; 14 (5S) : S338-S349.
Keywords: Child Abuse/*diagnosis, Contrast Media, Craniocerebral Trauma/*diagnostic imaging, Fractures, Bone/*diagnostic imaging/etiology, Humans, Infant, Infant, Newborn, Radiology, Rib Fractures/diagnostic imaging/etiology, Societies, Medical, Tomography, X-Ray C
The youngest children, particularly in the first year of life, are the most …
The youngest children, particularly in the first year of life, are the most vulnerable to physical abuse. Skeletal survey is the universal screening examination in children 24 months of age and younger. Fractures occur in over half of abused children. Rib fractures may be the only abnormality in about 30%. A repeat limited skeletal survey after 2 weeks can detect additional fractures and can provide fracture dating information. The type and extent of additional imaging for pediatric patients being evaluated for suspected physical abuse depends on the age of the child, the presence of neurologic signs and symptoms, evidence of thoracic or abdominopelvic injuries, and social considerations. Unenhanced CT of the head is the initial study for suspected intracranial injury. Clinically occult abusive head trauma can occur, especially in young infants. Therefore, head CT should be performed in selected neurologically asymptomatic physical abuse patients. Contrast-enhanced CT of the abdomen/pelvis is utilized for suspected intra-abdominal or pelvic injury. Particular attention should be paid to discrepancies between the patterns of injury and the reported clinical history. Making the diagnosis of child abuse also requires differentiation from anatomical and developmental variants and possible underlying metabolic and genetic conditions. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Flaherty EG, Perez-Rossello JM, Levine MA, Hennrikus WL, Christian CW, Crawford-Jakubiak JE, Leventhal JM, Lukefahr JL, Sege RD, MacMillan H, Nolan CM, Valley LA, Hurley TP, Cassady CI, Bulas DI, Cassese JA, Mehollin-Ray AR, Mercado-Deane MG, Milla SS, Thorne V, Sills IN, Blo. Evaluating children with fractures for child physical abuse. Pediatrics. 2014; 133 (2).
Keywords: Fractures
Fractures are common injuries caused by child abuse. Although the consequences …
Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures. Copyright \textcopyright 2014 by the American Academy of Pediatrics.
Glenn K, Nickerson E, Bennett CV, Naughton A, Cowley LE, Morris E, Murtagh U, Kontos K, Kemp AM. Head computed tomography in suspected physical abuse: time to rethink?. Archives of Disease in Childhood. 2021; 106 (5) : 461-466.
Keywords: Humans, Infant, *Tomography, X-Ray Computed/methods/statistics & numerical data, *Child Abuse/diagnosis/statistics & numerical data, Retrospective Studies, Male, Female, *Craniocerebral Trauma/diagnostic imaging, Child, Preschool, Practice Guidelines as T
BACKGROUND: National guidance recommends CT-head for all children <1 year old …
BACKGROUND: National guidance recommends CT-head for all children <1 year old with suspected physical abuse, and to be considered for those <2 years old to exclude abusive head trauma. OBJECTIVES: To investigate whether this guidance is followed, and the associations between clinical presentation and CT findings, to determine whether guidance could be refined. MATERIALS AND METHODS: A retrospective case note review of all children <2 years old who underwent medical assessment for suspected abuse (2009-2017). Outcome measures were frequency of CT-head, and diagnostic yield of intracranial injury, skull fracture or both. RESULTS: CT-head was undertaken in 60.3% (152/252) of children <12 months old and 7.8% (13/167) of those aged 12-24 months. The diagnostic yield in children who had a CT-head was 27.1% in children <6 months old, 14.3% in those 6-12 months old (p=0.07) and 42.6% (6/13) in those 12-24 months old. For those with head swelling or neurological impairment, it was 84.2% (32/38). In children <12 months old without these clinical features, the estimated prevalence of occult head injury was 6.1% (7/115). The strongest predictors of an abnormal CT-head were swelling to the head (OR 46.7), neurological impairment (OR 20.6) and a low haemoglobin (OR 11.8). CONCLUSION: All children <2 years of age with suspected physical abuse and neurological impairment or head swelling should undergo CT-head. Where the technical skills and the requisite expertise to interpret MRI exist, an MRI scan may be the optimal first-line neuroimaging investigation in infants who are neurologically stable with injuries unrelated to the head to minimise cranial radiation exposure.
Haney S, Scherl S, DiMeglio L, Perez-Rossello J, Servaes S, Merchant N. Evaluating Young Children With Fractures for Child Abuse: Clinical Report.. Pediatrics. 2025; 155 (2).
Keywords: Humans, *Child Abuse/diagnosis, *Fractures, Bone/diagnosis, Infant, Child, Preschool, Diagnosis, Differential, Child
Fractures are common injuries in childhood and can be caused by unintentional …
Fractures are common injuries in childhood and can be caused by unintentional injury, medical conditions, and child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, the consequences of incorrectly diagnosing child abuse in a child whose fractures have another etiology are also significant. This report aims to review recent advances in the understanding of fracture specificity, fracture mechanisms, and other medical conditions that predispose infants and children to fracture. This clinical report will aid pediatricians and pediatric care providers in developing an evidence-based differential diagnosis and performing appropriate evaluations when assessing a child with fractures.
Lane WG, Dubowitz H, Langenberg P. Screening for occult abdominal trauma in children with suspected physical abuse.. Pediatrics. 2009; 124 (6) : 1595-602.
Keywords: Abdominal Injuries/*diagnosis/*epidemiology, Alanine Transaminase/blood, Amylases/blood, Aspartate Aminotransferases/blood, Child Abuse/*diagnosis/*statistics & numerical data, Child Welfare/statistics & numerical data, Child, Preschool, Cross-Sectional S
OBJECTIVES: The goals were (1) to determine the prevalence of occult abdominal …
OBJECTIVES: The goals were (1) to determine the prevalence of occult abdominal trauma (OAT) in a sample of children with suspected physical abuse, (2) to assess the frequency of OAT screening, and (3) to assess factors associated with screening. METHODS: Charts of children evaluated for abusive injury were identified through a search of hospital discharge codes. Identified charts were reviewed to determine whether OAT screening occurred. Data on results of screening tests, abusive injuries identified, family demographic features, and characteristics of the emergency department visit were collected. RESULTS: Screening occurred for 51 (20%) of 244 eligible children. Positive results were identified for 41% of those screened and 9% of the total sample; 5% of children 12 to 23 months of age had OAT identified through imaging studies. Screening occurred more often in children presenting with probable abusive head trauma (odds ratio [OR]: 20.4 [95% confidence interval [CI]: 3.6-114.6]; P < .01), compared with those presenting with other injuries. Consultation with the child protection team (OR: 8.5 [95% CI: 3.5-20.7]; P < .01) and other subspecialists (OR: 24.3 [95% CI: 7.1-83.3]; P < .01) also increased the likelihood that OAT screening would occur. CONCLUSIONS: Our findings support OAT screening with liver and pancreatic enzyme measurements for physically abused children. This study also supports the importance of subspecialty input, especially that of a child protection team. Although many identified injuries may not require treatment, their role in confirming or demonstrating increased severity of maltreatment may be critical.
Lindberg DM, Blood EA, Campbell KA, Laskey AL, Berger RP. Predictors of screening and injury in contacts of physically abused children.. The Journal of Pediatrics. 2013; 163 (3) : 730-5.e1-3.
Keywords: Child, Child Abuse/*diagnosis/statistics & numerical data, Child Health Services/standards/*statistics & numerical data, Child, Preschool, *Family, Female, Guideline Adherence/*statistics & numerical data, Health Care Surveys, Humans, Infant, Infant, Newb
OBJECTIVE: To determine rates of screening in contacts of children evaluated …
OBJECTIVE: To determine rates of screening in contacts of children evaluated for physical abuse, and the relationship of clinical characteristics to screening recommendation and completion and injury identification. STUDY DESIGN: This is a planned secondary analysis of a prospective study of 1918 contacts of 1196 children referred for subspecialty abuse consultation in 20 US centers. We used multivariable logistic models to determine the relationship of index child characteristics, contact child characteristics, and shared characteristics to screening and injury identification. RESULTS: We identified injuries or disclosures of abuse in 180 (9.4%) contacts. Recommended screening was omitted in >20% of subjects for each screening modality. At least 1 screening test was more likely to be completed in contacts of index children of non-White race or Hispanic ethnicity (OR 1.45, 95% CI 1.13-1.87), with abuse-specific injuries (OR 2.15, 95% CI 1.63-2.83), with a confession (OR 2.18, 95% CI 1.17-4.07), when the history changed (OR 1.65, 95% CI 1.05-2.61), when an occult injury was found by imaging in the index child (OR 1.84, 95% CI 1.39-2.43), and when families lacked private insurance (OR 1.63, 95% CI 1.15-2.31). CONCLUSION: Completion of screening recommended for contacts of potentially abused children is relatively poor, despite high risk of injury. Several clinical and demographic factors were associated with increased contact screening.
McNamara CR, Wood JN, Lindberg D, Campbell KA, Poston S, Valente M, Antonucci M, Wolford J, Coombs C, Sahud H, Clarke J, Brink FW, Bachim A, Frasier LD, Harper NS, Melville JD, Laub N, Anderst J, Berger RP. Yield of skeletal surveys in national network of child abuse pediatricians: Age is key.. Child Abuse & Neglect. 2024; 157 : 106992.
Keywords: Humans, *Child Abuse/statistics & numerical data/diagnosis, Cross-Sectional Studies, Child, Preschool, Infant, Male, Female, United States/epidemiology, Age Factors, Fractures, Closed/diagnosis, Pediatricians/statistics & numerical data, Fractures, Bone/e
BACKGROUND: Skeletal surveys (SS) are recommended for the evaluation of …
BACKGROUND: Skeletal surveys (SS) are recommended for the evaluation of suspected physical abuse in children <2 years old. No guidelines exist for SS completion in children between 2 and 5 years old. OBJECTIVE: To determine rates of SS completion by age and examine variables associated with occult fracture identification in older children. PARTICIPANTS AND SETTING: Observational cross-sectional multi-center study of 10 US pediatric centers 2/2021-9/2022 including children <6 years old evaluated for physical child abuse. METHODS: The principal outcome is occult fracture identified on SS. Non-parametric tests were conducted from comparison between age groups and those with and without occult fractures. RESULTS: The rate of SS completion declined with increasing age from a high of 91 % in infants <6 months old to 7 % in children 5-5.9 years old. The proportion of SS with occult fractures also decreased with age. Of 450 children 2-5 years old with a SS, 20 [4 % (95 % CI: 3-8 %)] had an occult fracture. The rate of occult fractures among children 2-5 years old who were diagnosed with abuse and not admitted to the hospital was 0.3 % (95 % CI 0-0.6 %)]. Over 30 % of children 2-5 years old were diagnosed with child abuse by a child abuse pediatrician without completion of a SS. CONCLUSION: In children 2-5 years of age being evaluated for physical abuse, use of SS and the rate of occult fractures is low. The number of SS performed in children in this age group could potentially be decreased by up to 60 % by limiting SS to children admitted to the hospital.
Nguyen A, Hart R. Imaging of non-accidental injury; what is clinical best practice?. Journal of Medical Radiation Sciences. 2018; 65 (2) : 123-130.
Keywords: Child, *Child Abuse, Humans, Practice Guidelines as Topic, Wounds and Injuries/*diagnostic imaging/*etiology
Non-accidental injury (NAI) remains the leading cause of morbidity and …
Non-accidental injury (NAI) remains the leading cause of morbidity and mortality in children. Fractures are the second most common findings of NAI, after cutaneous lesions such as bruises and contusions. Imaging in NAI remains a controversial issue with little agreement concerning how, when and what imaging modalities should be used in the investigation of suspected cases. This review addresses the radiological investigations and findings of NAI, and the differential diagnoses of these findings. Adherence to the international guidelines for skeletal survey imaging is recommended. This ensures the content and quality of the radiographic series are of an optimal standard to improve the detection of occult fractures, and ensuring the accurate reporting of images. The involvement of a paediatric radiologist is important, if not essential in the diagnosis of NAI. In the evaluation of suspected cases, the role of the radiologist includes the detection of radiological findings suggestive of NAI, and the differentiation of these findings from normal variants and underlying pathologies. The diagnosis of NAI relies not only on radiological imaging, but also a combination of clinical and social findings. It is mandatory that all physicians work in close collaboration to improve diagnostic accuracy, as failure to diagnose NAI carries significant risk for morbidity.
Pfeifer CM, Henry MK, Caré MM, Christian CW, Servaes S, Milla SS, Strouse PJ. Debunking Fringe Beliefs in Child Abuse Imaging: AJR Expert Panel Narrative Review.. Ajr. American Journal of Roentgenology. 2021; 217 (3) : 529-540.
Keywords: Child Abuse/*diagnosis, Denial, Psychological, Diagnostic Imaging/*methods, Female, Humans, Infant, Magnetic Resonance Imaging, Male, Radiology, Reproducibility of Results, Tomography, X-Ray Computed
Child abuse is a global public health concern. Injuries from physical abuse may …
Child abuse is a global public health concern. Injuries from physical abuse may be clinically occult and not appreciable on physical examination. Imaging is therefore critical in identifying and documenting such injuries. The radiologic approach for a child who has potentially been abused has received considerable attention and recommendations according to decades of experience and rigorous scientific study. Nonetheless, fringe beliefs describing alternative explanations for child abuse-related injuries have emerged and received mainstream attention. Subsequently, imaging findings identified in abused children have been attributed to poorly supported underlying medical conditions, clouding the evidence basis for radiologic findings indicative of nonaccidental trauma. Fringe beliefs that attribute findings seen in child abuse to alternate pathologies such as genetic disorders, birth trauma, metabolic imbalances, vitamin D deficiency, and short-distance falls typically have limited evidence basis and lack professional society support. Careful review of the scientific evidence and professional society consensus statements is important in differentiating findings attributable to child abuse from fringe beliefs used to discount the possibility that a child's constellation of injuries is consistent with abuse. This review refutes fringe beliefs used to provide alternative explanations in cases of suspected child abuse and reinforces the key literature and scientific consensus regarding child abuse imaging.
Ruiz-Maldonado TM, Alsanea Y, Coats B. Age-related skull fracture patterns in infants after low-height falls.. Pediatric Research. 2023; 93 (7) : 1990-1998.
Keywords: Humans, Infant, Accidental Falls, *Skull Fractures/diagnostic imaging, *Craniocerebral Trauma, Tomography, X-Ray Computed, Head, Skull
BACKGROUND: Prior research and experience has increased physician understanding …
BACKGROUND: Prior research and experience has increased physician understanding of infant skull fracture prediction. However, patterns related to fracture length, nonlinearity, and features of complexity remain poorly understood, and differences across infant age groups have not been previously explored. METHODS: To determine how infant and low-height fall characteristics influence fracture patterns, we collected data from 231 head CT 3D reconstructions and quantified length and nonlinearity using a custom image processing code. Regression analysis was used to determine the effects of age and fall characteristics on nonlinearity, length, and features of fracture complexity. RESULTS: While impact surface had an important role in the number of cracks present in a fracture, younger infants and greater fall heights significantly affected most features of fracture complexity, including suture-to-suture spanning and biparietal involvement. In addition, increasing fracture length with increasing fall height supports trends identified by prior finite-element modeling. Finally, this study yielded results supporting the presence of soft tissue swelling as a function of fracture location rather than impact site. CONCLUSIONS: Age-related properties of the infant skull confer unique fracture patterns following head impact. Further characterization of these properties, particularly in infants <4 months of age, will improve our understanding of the infant skull's response to trauma. IMPACT: Younger infant age and greater fall heights have significant effects on many features of fracture complexity resulting from low-height falls. Incorporating multiple crack formation and multiple bone involvement into computational models of young infant skull fractures may result in increased biofidelity. Drivers of skull fracture complexity are not well understood, and skull fracture patterns in real-world data across infant age groups have not been previously described. Understanding fracture complexity relative to age in accidental falls will improve the understanding of accidental and abusive head trauma.
Strouse PJ, Owings CL. Fractures of the first rib in child abuse.. Radiology. 1995; 197 (3) : 763-5.
Keywords: Academic Medical Centers, Biomechanical Phenomena, Bone Diseases, Metabolic/diagnostic imaging, Brain Injuries/complications/diagnosis, Child Abuse/*diagnosis, Child, Preschool, Female, Humans, Incidence, Infant, Infant, Newborn, Male, Osteogenesis Imperf
PURPOSE: To evaluate the incidence and specificity of fracture of the first rib …
PURPOSE: To evaluate the incidence and specificity of fracture of the first rib as an indicator of child abuse and to determine a mechanism of fracture. MATERIALS AND METHODS: All infants and young children with rib fractures who were seen at the radiology department of an academic medical center over a 2-year period were identified from the radiology data base. RESULTS: Rib fractures were attributed to child abuse in 12 of 35 children identified. Apart from a neonate with congenital osteogenesis imperfecta, only three children, all abused, had first-rib fracture, one bilaterally. Two additional children with first-rib fracture were identified from years prior to the study period. In four children, first-rib fractures were "isolated," without fractures of adjacent bones. CONCLUSION: Child abuse should be considered in cases of pediatric rib fracture, particularly fracture of the first rib. Possible mechanisms for first-rib fracture include impact force, compressive force, and shaking or acute axial load (slamming), which cause an indirect fracture.
Trout AT, Strouse PJ, Mohr BA, Khalatbari S, Myles JD. Abdominal and pelvic CT in cases of suspected abuse: can clinical and laboratory findings guide its use?. Pediatric Radiology. 2011; 41 (1) : 92-8.
Keywords: Abdominal Injuries/*diagnostic imaging, Child Abuse/*diagnosis, Child, Preschool, Female, Humans, Infant, Infant, Newborn, Male, Pelvis/*diagnostic imaging, Physical Examination/methods, Retrospective Studies, Tomography, X-Ray Computed, Ultrasonography
BACKGROUND: Incomplete history and concern for occult injury in suspected child …
BACKGROUND: Incomplete history and concern for occult injury in suspected child abuse occasionally results in CT screenings of the abdomen and pelvis. At our institution, we noted that these exams were infrequently positive. OBJECTIVE: To identify clinical or laboratory criteria that may predict intra-abdominal injury and guide the use of abdominal and pelvic CT in this population. MATERIALS AND METHODS: This retrospective review involved 68 children older than 36 months who had a CT of the abdomen/pelvis for suspected abuse. CT results and patient charts were reviewed for physical exam and historical and laboratory variables. RESULTS: CTs were positive in 16% of patients (11/68). Hypoactive/absent bowel sounds (P = 0.01, specificity = 94.7%) and AST and ALT values greater than twice normal (P = 0.004 and P = 0.003 respectively, NPV = 93.6%) were significantly associated with positive CTs. Multiple abnormal physical exam or laboratory findings were also significantly associated with positive CTs (P = 0.03 and P = 0.002 respectively, specificity = 91.3% and NPV = 93.6% respectively). CONCLUSION: CTs of the abdomen and pelvis are infrequently positive in cases of suspected abuse. To reduce radiation exposure, CTs should only be ordered if there are findings indicating that they may be positive. In our population, these findings include absent/hypoactive bowel sounds, LFTs greater than twice normal and ≥2 abnormal labs or physical exam findings.
Wood JN, Fakeye O, Feudtner C, Mondestin V, Localio R, Rubin DM. Development of guidelines for skeletal survey in young children with fractures. Pediatrics. 2014; 134 (1) : 45-53.
Keywords: Child abuse,Child maltreatment,Fracture,Skeletal survey,Trauma
OBJECTIVE: To develop guidelines for performing initial skeletal survey (SS) in …
OBJECTIVE: To develop guidelines for performing initial skeletal survey (SS) in children <24 months old with fractures, based on available evidence and collective judgment of experts from diverse pediatric specialties. METHODS: Following the Rand/UCLA Method, a multispecialty panel of 13 experts applied evidence from a literature review combined with their own expertise in rating the appropriateness of performing an SS for 525 clinical scenarios involving fractures in children <24 months old. After discussion on the initial ratings, panelists rerated SS appropriateness for 240 revised scenarios and deemed that SSs were appropriate in 191 scenarios. The panelists then assessed in which of those 191 scenarios SSs were not only appropriate, but also necessary. RESULTS: Panelists agreed that SS is "appropriate" for 191 (80%) of 240 scenarios rated and "necessary" for 175 (92%) of the appropriate scenarios. Skeletal survey is necessary if a fracture is attributed to abuse, domestic violence, or being hit by a toy. With few exceptions, SS is necessary in children without a history of trauma. In children <12 months old, SS is necessary regardless of the fracture type or reported history, with rare exceptions. In children 12 to 23 months old, the necessity of obtaining SS is dependent on fracture type. CONCLUSIONS: A multispecialty panel reached agreement on multiple clinical scenarios for which initial SS is indicated in young children with fractures, allowing for synthesis of clinical guidelines with the potential to decrease disparities in care and increase detection of abuse. Copyright \textcopyright 2014 by the American Academy of Pediatrics.
Yeung F, Smith J, Mendoza-Londono R, O'Connor C, Howard A, Sorbara J, Schwartz S. Fracture prevalence in children diagnosed with Ehlers-Danlos Syndrome and Generalized Joint Hypermobility.. Child Abuse & Neglect. 2024; 153 : 106828.
Keywords: Humans, *Ehlers-Danlos Syndrome/epidemiology/complications, *Joint Instability/epidemiology, Male, Female, Prevalence, Retrospective Studies, Child, Preschool, Child, Infant, *Fractures, Bone/epidemiology/etiology, Adolescent
BACKGROUND: There is limited understanding of the hypothesized association …
BACKGROUND: There is limited understanding of the hypothesized association between the Ehlers-Danlos Syndromes (EDS), hypermobility and fractures in children. Despite this, EDS and hypermobility continue to be raised in the legal setting as possible causes of unexplained fractures in infants where there is a concern for physical abuse. Further understanding is needed regarding fractures in children with EDS and hypermobility. OBJECTIVE: This study assessed fracture prevalence and characteristics in children diagnosed with EDS and Generalized Joint Hypermobility (GJH). The secondary outcome was fracture prevalence in infants <1 year of age. PARTICIPANTS AND SETTING: Children aged <18 years with EDS or GJH seen in a single-center EDS clinic from April 2017 to December 2021 were included. Diagnoses were based on the 2017 international classification. Exclusion criteria were concurrent medical conditions associated with bone fragility. METHODS: This retrospective descriptive study examined variables including fracture history, fracture location, fracture type, age of sustaining fracture, and injury mechanism. Descriptive statistics were used for analysis. RESULTS: Fracture prevalence was 34.6 % (9/26, 95 % CI [16.3, 52.9]) in the EDS population and 25.4 % (15/59, 95 % CI [14.3, 36.5]) in the GJH population. No fractures occurred in infancy. Most fractures occurred in the limbs. There were no rib or skull fractures. Most fractures were the result of an identifiable injury event. CONCLUSION: In a cohort of children with formally diagnosed EDS or GJH, fractures occurred commonly in ambulatory children and generally in the limbs from identifiable events. This study does not support EDS or GJH as a cause of fractures in infancy.
