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.
