Kevin P. Coulter

Comparison of Computed Tomography and Chest Radiography in the Detection of Rib Fractures in Abused Infants.

PURPOSE Chest radiographs (CXR) are the standard method for evaluating rib fractures in abused infants. Computed tomography (CT) is a sensitive method to detect rib fractures. The purpose of this study was to compare CT and CXR in the evaluation of rib fractures in abused infants. METHODS This retrospective study included all 12 abused infants identified from 1999 to 2004 who had rib fractures and both CXR and CT (8 abdomen CTs, 4 chest CTs). CT exams had been performed for clinical indications, and were obtained within one day of the CXR. Studies were reviewed by two pediatric radiologists to determine the number, locations, and approximate ages of the rib fractures. A total of 225 ribs were completely (192) or partially (33) seen by CT, and the matched ribs on CXR were used for the analysis. RESULTS The mean patient age was 2.5 months (1.2-5.6), with seven females and five males. While 131 fractures were visualized by CT, only 79 were seen by CXR (p<.001). One patient had fractures only seen by CT. There were significantly (p<.05) more early subacute (24 vs. 4), subacute (47 vs. 26), and old fractures (4 vs. 0) seen by CT than by CXR. Anterior (42 vs. 11), anterolateral (21 vs. 12), posterolateral (9 vs. 3) and posterior (39 vs. 24) fractures were better seen by CT than by CXR (p<.01). Bilateral fractures were detected more often by CT (11) than by CXR (6). CONCLUSIONS While this study group is small, these findings suggest that CT is better than CXR in visualizing rib fractures in abused infants.

Follow-Up Skeletal Surveys for Suspected Non-Accidental Trauma: Can a More Limited Survey Be Performed without Compromising Diagnostic Information?.

OBJECTIVE Follow-up skeletal surveys have been shown to improve the rate of fracture detection in suspected cases of non-accidental trauma (NAT). As these studies are performed in a particularly radiosensitive population, it is important to evaluate if all of the (approximately 20) radiographs obtained at repeat skeletal survey are clinically useful. Our goal was to evaluate if certain radiographs can be excluded at follow-up skeletal survey without compromising the clinical efficacy. METHODS This retrospective study included 22 cases of suspected NAT (average age 3.8 months, range 0.7-15 months) in which patients received both initial and follow-up bone surveys. The follow-up survey was performed an average of 16.7 days (range 11-29 days) after the initial survey. Radiographs were reviewed by 2 pediatric radiologists, with discrepancies resolved by consensus. In addition, we combined our data with data from all known previously published reports of follow-up skeletal surveys for NAT for meta-analysis. RESULTS A total of 36 fractures were found on the initial bone survey in 16/22 patients (73%). Six patients had no fractures detected at initial survey. Follow-up bone surveys demonstrated an additional 3 fractures (2 extremities and 1 rib) in 3/22 cases (14%); 1 was in a patient whose initial survey was negative. No additional fractures in the skull, spine, pelvis, feet, or hands were detected in any case. In combination with patients reported in the literature (194 patients total) no new fracture of the skull, spine, pelvis, or hands was detected at follow-up survey. The skull, spine and pelvis radiographs are the highest dose-exposure studies of the skeletal survey. CONCLUSION AND PRACTICE IMPLICATIONS If no injury is detected or suspected in the pelvis, spine, hands, or skull at initial bone survey for suspected NAT, a limited follow-up skeletal survey which excludes the pelvis, lateral spine, hands, and skull should be considered to limit radiation exposure without limiting diagnostic information.

Retrospective evaluation and dating of non-accidental rib fractures in infants

AIM To describe the sequential appearance of healing rib fractures on initial and follow-up radiographs using published guidelines in approximating the age of rib fractures in infants with the aim of establishing a more objective method of dating rib fractures by measuring the thickness of the callous formation. MATERIALS AND METHODS This was a retrospective analysis of initial and follow-up digital skeletal surveys of infants less than 12 months of age performed between January 2008 and January 2012 at the University of California Davis Childrens Hospital. Six radiological features of rib fractures evaluating the appearance of the callous formation (C stage) and fracture line (F stage) were assessed. Patients with osteogenesis imperfecta, known vitamin D deficiency, and skeletal or metabolic dysplasia were not included in the study. Thereafter, callous thickness was measured and recorded for each stage. RESULTS Sixteen infants (age range 1-11 months, seven males and nine females) with 23 rib fractures were analysed. The thickness of the callous formation follows a predictable pattern advancing one stage after a 2-week follow-up with progressive callous thickening starting from stage 2, peaks at around stage 4, and then tapers and remodels until it almost disappears when the fracture is healed at stage 6. CONCLUSION It appears that rib fractures in infants follow a predictable pattern of healing. Measuring the thickness of the callous formation is a more objective way of guiding the radiologist in estimating the age of the fracture.

Optimizing bone surveys performed for suspected non-accidental trauma with attention to maximizing diagnostic yield while minimizing radiation exposure: utility of pelvic and lateral radiographs

BackgroundSkeletal surveys for non-accidental trauma (NAT) include lateral spinal and pelvic views, which have a significant radiation dose.ObjectiveTo determine whether pelvic and lateral spinal radiographs should routinely be performed during initial bone surveys for suspected NAT.Materials and methodsThe radiology database was queried for the period May 2005 to May 2011 using CPT codes for skeletal surveys for suspected NAT. Studies performed for skeletal dysplasia and follow-up surveys were excluded. Initial skeletal surveys were reviewed to identify fractures present, including those identified only on lateral spinal and/or pelvic radiographs. Clinical information and MR imaging was reviewed for the single patient with vertebral compression deformities.ResultsOf the 530 children, 223 (42.1%) had rib and extremity fractures suspicious for NAT. No fractures were identified solely on pelvic radiographs. Only one child (<0.2%) had vertebral compression deformities identified on a lateral spinal radiograph. This infant had rib and extremity fractures and was clinically paraplegic. MR imaging confirmed the vertebral body fractures.ConclusionSince no fractures were identified solely on pelvic radiographs and on lateral spinal radiographs in children without evidence of NAT, nor in nearly all with evidence of NAT, inclusion of these views in the initial evaluation of children for suspected NAT may not be warranted.

An inborn error of bile salt transport with features mimicking abusive head trauma.

Fat malabsorption in children may cause deficiencies of vitamins A, D, E, and K, with severe complications. We present an infant admitted with subdural hematoma, retinal hemorrhages, and failure to thrive who was initially diagnosed with suspected abuse and neglect. She was found to have vitamin K-deficient-coagulopathy due to fat malabsorption, caused by a disorder of bile salt transport: progressive familial intrahepatic cholestasis type 2. The baby had been hospitalized 3 months earlier with vitamin D-deficient hypocalcemia, but her underlying disorder went unrecognized. We believe this is the first report of subdural hematoma and retinal hemorrhage attributed to a bile salt transport disorder and, perhaps more significant, the first report of retinal hemorrhages and exudative retinal detachment linked to cholestasis-induced malabsorption (which resulted in the vitamin K-deficient-coagulopathy, anemia, and hypoalbuminemia that likely caused the retinal findings). Our patient’s course underscores the importance of recognizing this family of disorders promptly to prevent serious injury or death and inaccurate (and emotionally traumatizing) accusations against caregivers.

Characteristics of rib fractures in child abuse-the role of low-dose chest computed tomography

Objectives Our aim is to describe the radiologic characteristics of rib fractures in clinically diagnosed cases of child abuse and suggest a complementary imaging for radiographically occult injuries in highly suspicious cases of child abuse. Methods Retrospective analysis of initial and follow-up skeletal surveys and computed tomography (CT) scans of 16 patients younger than 12 months were reviewed after obtaining approval from our institutional review board. The number, location, displacement, and age of the rib fractures were recorded. Results Out of a total 105 rib fractures, 84% (87/105) were detected on the initial skeletal survey. Seventeen percent (18/105) were seen only after follow-up imaging, more than half of which (11/18) were detected on a subsequent CT. Majority of the fractures were posterior (43%) and anterior (30%) in location. An overwhelming majority (96%) of the fractures are nondisplaced. Conclusions Seventeen percent of rib fractures analyzed in the study were not documented on the initial skeletal survey. Majority of fractures are nondisplaced and located posteriorly or anteriorly, areas that are often difficult to assess especially in the acute stage. The CT scan is more sensitive in evaluating these types of fractures. Low-dose chest CT can be an important imaging modality for suspicious cases of child abuse when initial radiographic findings are inconclusive.

Long-term impact of abusive head trauma in young children

OBJECTIVE Abusive head trauma is the leading cause of physical abuse deaths in children under the age of 5 and is associated with severe long-lasting health problems and developmental disabilities. This study evaluates the long-term impact of AHT and identifies factors associated with poor long-term outcomes (LTOs). METHODS We used the Truven Health MarketScan Research Claims Database (2000-2015) to identify children diagnosed with AHT and follow them up until they turn 5. We identified the incidence of behavioral disorders, communication deficits, developmental delays, epilepsy, learning disorders, motor deficits, and visual impairment as our primary outcomes. RESULTS The incidence of any disability was 72% (676/940) at 5 years post-injury. The rate of developmental delays was 47%, followed by 42% learning disorders, and 36% epilepsy. Additional disabilities included motor deficits (34%), behavioral disorders (30%), visual impairment (30%), and communication deficits (11%). Children covered by Medicaid experienced significantly greater long-term disability than cases with private insurance. In a propensity-matched cohort that differ primarily by insurance, the risk of behavioral disorders (RD 36%), learning disorders (RD 30%), developmental delays (RD 30%), epilepsy (RD 18%), and visual impairment (RD 12%) was significantly higher in children with Medicaid than kids with private insurance. CONCLUSION AHT is associated with a significant long-term disability (72%). Children insured by Medicaid have a disproportionally higher risk of long-term disability. Efforts to identify and reduce barriers to health care access for children enrolled in Medicaid are critical for the improvement of outcomes and quality of life.

Blunt Intraoral Trauma Resulting in Internal Carotid Artery Dissection and Infarction in a Child.

A 16-month-old child fell forward onto her toothbrush sustaining minor oropharyngeal injury. The following day, she became acutely lethargic with localizing neurologic signs of a cerebrovascular infarct. CTA and MR imaging demonstrated occlusion of the right internal carotid artery with a large right middle cerebral artery territory infarction. She was treated with decompressive craniectomy and anticoagulation but remained weak on the left side. Pediatric oropharyngeal injuries can rarely be complicated by internal carotid artery injury with dissection, thrombosis, or embolization to the cerebral circulation. For the best outcome, carotid dissection treatment requires prompt diagnosis at the initial onset of neurologic symptoms. However, further research is needed to determine the best management and advanced imaging work-up for neurologically intact children.

Non-accidental Trauma

This chapter presents the different imaging modalities that may be used in the radiographic diagnosis of non-accidental trauma, with particular emphasis on the skeletal survey. The different fracture patterns related to non-accidental trauma are then reviewed, including high-, moderate-, and low-specificity lesions. Fracture aging is also presented. Finally, mimics of non-accidental trauma are discussed, with more detailed presentation of osteogenesis imperfecta and rickets.

60 COMPARISON OF COMPUTED TOMOGRAPHY AND CHEST RADIOGRAPHY IN THE DETECTION OF RIB FRACTURES IN ABUSED INFANTS

Purpose A rib fracture in an infant usually results from nonaccidental trauma. Chest radiographs (CXR) are currently the standard method for evaluating rib fractures in abused infants. Computed Tomography (CT) is known to be a sensitive method to detect rib fractures. However, to date no studies comparing these two methods in abused infants have been reported. The purpose of this study was to compare CT and CXR in the evaluation of rib fractures in abused infants. Methods This retrospective, IRB-approved study included all 11 abused infants identified from 1999-2004 who had rib fractures and both CXR and CT (8 abdomen CTs, 3 chest CTs). CT exams had been performed for clinical indications. Studies were reviewed by two pediatric radiologists to determine the number, locations, and approximate age of the rib fractures. A total of 201 ribs were completely (168) or partially (33) seen on the CT exams, and the matched ribs on CXR were used for the analysis. Summary of Results The mean age of the patients was 9.5 weeks with a range of 5.3 to 20.6 weeks. There were 4 males and 7 females. Eight infants had both their CXR and CT on the same day, and 3 infants CXRs and CTs were one day apart. Although 127 fractures were visualized by CT, only 76 were seen on CXR (p≤.001). One patient had fractures only seen by CT. There were significantly (p≤.05) more early subacute (86% vs. 14%), subacute (64% vs. 36%), and old fractures (100% vs. 0%) seen by CT than by CXR. There was no significant difference in the number of acute or late subacute fractures seen by CT or CXR. Fractures located anteriorly (73% vs. 27%) and posteriorly (64% vs. 36%) were better seen by CT than by CXR (p≤.01). Significantly (p≤.05) more bilateral fractures were seen by CT (67%) than by CXR (33%). Two non-fracture abnormalities were detected by CT: one pleural effusion and one liver laceration. Conclusions While the number of patients studied here is small, these findings suggest that CT is better than CXR in visualizing rib fractures in abused infants.