CASE 70

By: Dr. Amna Kashgari MD,SSC-Rad

HISTORY: An 18-month-baby with shortness of breath and fever.

What are your findings?

What is your diagnosis?

What is your recommendation?

FINDINGS:

Frontal chest radiograph shows multiple rib fractures with callous formation involving the posterior and lateral ribs at various levels.

The lung shows evidence of small airway disease most likely related to viral infection.

DIFFERENTIAL DIAGNOSIS:

• Non-accidental injury.

• Osteogenesis imperfecta.

• Caffey’s disease.

DIAGNOSIS:

Non-accidental injury.

Recommendation:

• Skeletal survey (AP chest, AP and lateral Skull, extremities and lateral cervical and Thoracolumber spine, oblique ribs view).

• CT head as the patient is less than 1 year.

PEARLS AND DISCUSSION:

Battered child syndrome considers the 3rd most common cause of death in children after sudden infant death syndrome and true accident.

The radiologist should be able to detect subtle non-accidental injury and correlate the fracture with the mechanism of injury. He is obligated to report the suspected cases to referring physician and or authorities immediately.

The most common injury in non-accidental injury is skeletal injury that is seen in 50-80% and skeletal survey is the cornerstone radiological examination in suspected physical abuse.

The ACR defines the skeletal survey as ‘a systematically performed series of radiographic images that encompasses the entire skeleton’.

It includes:

• Appendicular skeleton:

  •   Humeri (AP).

  •   Forearms (AP).

  •   Hands (oblique, PA).

  •   Femurs (AP)

  •   Lower legs (AP).

  •   Feet (AP).

• Axial Skeleton:

  •   Thorax (AP and lateral).

  •   Pelvis (AP; including mid and lower lumbar spine).

  •   Lumbar spine (lateral).

  •   Cervical spine (lateral).

  •   Skull (frontal and lateral).

Types and diagnostic utility of skeletal injury:

Metaphyseal Fracture –Corner fracture	Pathognomonic (rare)
Rib fractures – posteriomedial	High specificity
Scapular fracture	High specificity
Spinous process fractures	High specificity
Sternal fractures	High specificity
Complex skull fracture	Moderate specificity
Fractures with different age	Moderate specificity
Multiple fractures	Moderate specificity
Vertebral body fracture	Moderate specificity
Long bone fracture	Low specificity
Clavicular fracture	Low specificity
Linear skull fracture	Low specificity

It is important to know classic metaphyseal lesion of the distal femur and multiple healed posterior rib fractures findings are highly specific for abuse and should be reported to the medical team.

FURTHER READING:

1. Gael J. Lonergan, Andrew M. Baker et al. Child Abuse: Radiologic-Pathologic Correlation. RadioGraphics 2003; 23:811–84

2. Amaka Offiah & Rick R. van Rijn et al. Skeletal imaging of child abuse (non-accidental injury). Pediatric Radiol (2009) 39:461–470