Tag Archives: Pediatrics

Student Corner: Pediatric Non-Accidental Trauma

October 14, 2015

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A 4-week-old girl was brought to the ED with right thigh swelling after reportedly getting caught up in the restraints of her car seat. Lower extremity radiographs revealed a healing right femur fracture, as well as multiple fractures of the left lower extremity. In light of these findings, a complete skeletal survey was performed. Look at the chest radiograph below. Other than the striking number of fractures that you see, what else do you notice about them?

NAT Image 1

The various posterior rib fractures are in different stages of healing. For example, the left 3rd through 5th posterior rib fractures (red, below) appear most acute, while the left 7th-9th ribs (blue) show some degree of healing. The rib fractures on the right side (yellow) show more substantial callous formation (2nd through 9th, and 11th).

NAT Image 2

Unfortunately, these findings strongly suggest that this patient was the victim of non-accidental trauma (NAT). There are many radiographic findings suggestive of NAT, but some of them are more specific than others.

Highly specific findings include:

  • Rib fractures (especially posterior)
  • Metaphyseal lesions – “bucket handle” or “corner” fractures
  • Scapular fractures
  • Spinous process fractures
  • Sternal fractures

Now, let’s take a closer look at the lower extremity fractures that were initially discovered.

NAT Image 3

These are classic metaphyseal fractures, which we just learned were some of the most highly specific findings for NAT. The child has a healing metaphyseal fracture of the right distal femur. There is also a metaphyseal fracture at the right proximal tibia.

NAT Image 4 crop

The left distal femur shows an acute transverse metaphyseal fracture. Metaphyseal fractures are also seen involving the left distal tibia. Finally, notice the periosteal reaction along the shafts of the left tibia and fibula, right lateral distal femur, and right fibula.

It should be noted that it is very important to rule out other potential causes of such fractures, like Vitamin D deficiency or osteogenesis imperfecta, since a diagnosis or even the suggestion of NAT will bring about a wide range of social, economic, and legal consequences.

The images and fracture patterns above are not all-inclusive for NAT as many fractures can occur. It is imperative that physicians utilize their clinical index of suspicion along with radiologic imaging in search of NAT.

What should be included in a typical skeletal survey when NAT is suspected? The American College of Radiology suggests the following protocol:

  • Chest (AP, lateral and bilateral obliques to include the thoracic and upper lumbar spine)
  • Pelvis (AP, to include the mid-lumbar spine)
  • Lumbosacral spine (lateral)
  • Cervical spine (AP and lateral)
  • Skull (Fontal and lateral, oblique view as needed)
  • Humeri (AP)
  • Forearms (AP)
  • Femurs (AP)
  • Lower legs (AP)
  • Hands and Feet (AP)

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Images courtesy of Dr. Thomas Sanchez

References:

Jayakumar P, Barry M, Ramachandran M. Orthopaedic aspects of paediatric non-accidental injury. J Bone Joint Surg Br. 2010 Feb;92(2):189-95. doi: 10.1302/0301-620X.92B2.22923. Review. PubMed PMID: 20130307.

Johnson K. Skeletal aspects of non-accidental injury. Endocr Dev. 2009;16:233-45. doi: 10.1159/000223698. Epub 2009 Jun 3. Review. PubMed PMID: 19494670.

Ng CS, Hall CM. Costochondral junction fractures and intra-abdominal trauma in non-accidental injury (child abuse). Pediatr Radiol. 1998 Sep;28(9):671-6. PubMed PMID: 9732490.

Leventhal JM, Thomas SA, Rosenfield NS, Markowitz RI. Fractures in young children. Distinguishing child abuse from unintentional injuries. Am J Dis Child. 1993 Jan;147(1):87-92. PubMed PMID: 8418609.

Author:  Mitchell Datlow

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Pediatric aspiration chest xray

March 2, 2013

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This a chest xray one of my colleagues sent me.  He is a 21 month old male who possibly aspirated part of an apple:

Aspiration 1

The interesting portion of this radiograph is the overall hyperinflation of the right lung when compared to the left.  With this clinical history, asymmetric hyperinflation is highly concerning for aspirated foreign body.  The foreign body acts as a “ball-valve,” trapping air on exhalation and therefore causing a hyperinflated lung.  It can, but often doesn’t lead to pneumothorax. 

In this case the asymmetry was visible on upright radiograph and the diagnosis of retained foreign body was made.  The child had a bronchoscopy and an apple fragment was pulled out of his right mainstem bronchus. 

Other imaging tricks in aspiration include decubitus films and expiratory films. 

1.  Expiratory films:  have the patient expire and take a plain upright radiograph.  This may accentuate the asymmetry if the ball-valve effect is causing air trapping.

2.  Decubitus films:  When laying on one’s side the dependent lung should be asymmetrically smaller than the opposing lung.  If one of the lungs stays symmetric while in the dependent position, this can be a sign of air trapping.  It is recommended to obtain films in both decubitus positions (left and right).

Also consider CT imaging as a final imaging modality.  However, the definitive study is bronchoscopy if your suspicion is high. 

Author:  Russell Jones, MD

Image Contributor:  Kendra Grether-Jones, MD

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