2014 SPR Postgraduate Course Child Abuse & Not Child Abuse: Focus on Radiography Moderators: Jeannette M. Perez-Rossello, MD Peter J. Strouse, MD, FACR 2014 SPR PG Course A 7 month old infant presents with fussiness and a heart murmur. A radiograph of the chest was obtained which shows which of the following? A. No abnormality B. An acute rib fracture C. A healing rib fracture D. A rib fracture on indeterminate age E. A clavicle fracture Answer: C. A healing rib fracture Rational: There is a fracture of the lateral aspect of the left 7th rib. There is evidence of surrounding mature (hard) callus indicating healing (C). Option A is incorrect because of the fracture Option B is incorrect because of the callus. Option D is incorrect because the hard callus would be inconsistent with a recent acute injury. Option E is incorrect because the clavicles are normal. References: 1. Barsness KA, Cha ES, Bensard DD, Calkins CM, Partrick DA, Karrer FM, et al. The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma. 2003;54(6):1107-10. 2. Cadzow SP, Armstrong KL. Rib fractures in infants: red alert! The clinical features, investigations and child protection outcomes. Journal of Paediatrics & Child Health. 2000;36(4):322-6. 3. Williams RL, Connolly PT. In children undergoing chest radiography what is the specificity of rib fractures for non-accidental injury? Arch Dis Child. 2004;89(5):490-2. 4. Cosway B, Mathura N, Bredow M, Fraser J, Mott A, Rawlinson A, et al. Diagnostic indicators for NAI in children with RIB fractures; a retrospective analysis of 52 infants. Archives of Disease in Childhood. 2011;96(Suppl 1):A99. 5. Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008;337:a1518. 6. Strouse PJ, Boal DKB. Child Abuse. In: Coley BD, editor. Caffey's Pediatric Diagnostic Imaging. 12th ed. Philadelphia: Saunders; 2013. p. 1587-98. A solitary rib fracture incidentally encountered in an otherwise normal child should immediately prompt which of the following? A. Skeletal survey B. Verbal conversation with the referring health care provider C. Discussion with the family D. Dictation and finalization E. Chest CT Correct answer is B. Verbal conversation with the referring health care provider Rational: Rib fractures are strongly associated with child abuse in infancy. The findings should be immediately communicated to the ordering health care provider (B). Option A is incorrect since the skeletal survey should be done only after the clinician is informed of the finding and a skeletal survey has been requested. If abuse is a concern, a skeletal survey is usually the next imaging study Option C is incorrect because the findings are best discussed with the family in the clinical context by the referring clinician/member of the child protection team. Option D is incorrect since the discussion with the clinician may inform the final dictation and the conversation should be documented in the report. Option E is incorrect since chest CT is generally reserved for a small minority of patients as a problem solving tool. This infant also had multiple classic metaphyseal lesions and forearm fractures on the subsequent skeletal survey and a mandated report was filed. References: 1. American Academy of Pediatrics Section on Radiology (2009). "Diagnostic imaging of child abuse." Pediatrics 123(5): 1430-1435. 2. American College of Radiology (2011). ACR–SPR Practice Guideline for Skeletal Surveys in Children Revised 2011 (Resolution 54)*. Reston, VA, American College of Radiology: 1-6 3. American College of Radiology Expert Panel on Pediatric Imaging (2011). ACR Appropriateness Criteria on suspected physical abuse-child. J Am Coll Radiol, American College of Radiology. 8: 87-94. 4. Wootton-Gorges SL, Stein-Wexler R, Walton JW, Rosas AJ, Coulter KP, Rogers KK. Comparison of computed tomography and chest radiography in the detection of rib fractures in abused infants. Child Abuse Negl. 2008;32(6):659-63. 5. American College of Radiology. ACR Practice Guideline for Communicating of Diagnostic Imaging Findings (Res. 11). American College of Radiology: ACR Standards. Reston, VA: American College of Radiology; 2010. Which of the following is true regarding the findings? A. Fracture possibly associated with child abuse B. Classic metaphyseal lesion and definitely child abuse C. Probable metabolic abnormality such as rickets D. Normal finding with metaphyseal step-off E. Osteomyelitis Answer is D. Normal finding with metaphyseal step-off The radiograph depicts a normal metaphyseal step-off where there is a focal paucity of cortical bone due to subperiosteal bone collar. Option A is not correct. This finding does not represent a fracture and therefore child abuse is not suggested. Option B is not correct. This finding does not represent a classic metaphyseal lesion and therefore child abuse is not suggested. Option C is not correct. There are no findings to suggest a metabolic abnormality such as metaphyseal cupping and flaring to suggest rickets. Option D is correct. This finding is a normal metaphyseal step- off with 90 degree angulation at the metaphysic and commonly occurs in the distal femur. Option E is not correct. There is no lucency or periosteal reaction to suggest osteomyelitis. References: 1. Kleinman PK, Belanger PL, Karellas A, Spevak MR. AJR Am J Roentgenol. 1991 Apr;156(4):781-3. Normal metaphyseal radiologic variants not to be confused with findings of infant abuse. 2. Kleinman PK, Sarwar ZU, Newton AW, Perez-Rossello JM, Rebello G, Herliczek TW. Metaphyseal fragmentation with physiologic bowing: a finding not to be confused with the classic metaphyseal lesion. AJR Am J Roentgenol. 2009 May;192(5):1266-8 3. Dwek JR. The radiographic approach to child abuse.Clin Orthop Relat Res. 2011 Mar;469(3):776-89.