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Colleran GC, Fossmark M, Rosendahl K, Argyropoulou M, Mankad K, Offiah AC. ESR Essentials: imaging of suspected child abuse-practice recommendations by the European Society of Paediatric Radiology. Eur Radiol 2024:10.1007/s00330-024-11052-4. [PMID: 39289300 DOI: 10.1007/s00330-024-11052-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 08/01/2024] [Accepted: 08/06/2024] [Indexed: 09/19/2024]
Abstract
The goal of this paper is to provide a useful desktop reference for the imaging of suspected child abuse with clear, age-specific pathways for appropriate evidence-based imaging and follow-up. We aim to provide a road map for the imaging evaluation and follow-up of this important and vulnerable cohort of patients presenting with signs and symptoms concerning for inflicted injury. As the imaging recommendations differ for children of different ages, we provide a flowchart of the appropriate imaging pathway for infants, toddlers, and older children, which allows ease of selection of which children should undergo skeletal survey, non-contrast computed tomography (CT) brain with 3-dimensional (D) reformats, and magnetic resonance imaging (MRI) of the brain and whole spine. For ease of review, we include a table of the common intracranial and spinal patterns of injury in abusive head trauma. We summarise search patterns, areas of review, and key findings to include in the report. To exclude skeletal injury, infants and children under 2 years of age should undergo a full skeletal survey in accordance with national guidelines, with a limited follow-up skeletal survey performed 11-14 days later. For children over 2 years of age, the need for skeletal imaging should be decided on a case-by-case basis. All infants should undergo a non-contrast-enhanced CT brain with 3-D reformats. If this is normal with no abnormal neurology, then no further neuroimaging is required. If this is abnormal, then they should proceed to MRI brain and whole spine within 2-5 days. Children older than 1 year of age who have abnormal neurology and/or findings on skeletal survey that are suggestive of inflicted injury should undergo non-contrast CT brain with 3-D reformats and, depending on the findings, may also require MRI of the brain and whole spine. We hope that this will be a helpful contribution to the radiology literature, particularly for the general radiologist with low volumes of paediatrics in their practice, supporting them with managing these important cases when they arise in daily practice. KEY POINTS: The choice of initial imaging (skeletal survey and/or brain CT) depends on the age of the child in whom abuse is suspected. A follow-up skeletal survey is mandatory 11-14 days after the initial survey. If an MRI of the brain is performed, then an MRI of the whole spine should be performed concurrently.
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Affiliation(s)
| | - Maria Fossmark
- Department of Radiology, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Karen Rosendahl
- Department of Radiology, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Maria Argyropoulou
- Department of Clinical Radiology and Imaging, Medical School, University of Ioannina, Ioannina, Greece
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - Amaka C Offiah
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK.
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Cantarelli Rodrigues T, Godoy IRB, Serfaty A. Pediatric Wrist. Semin Musculoskelet Radiol 2024; 28:408-423. [PMID: 39074724 DOI: 10.1055/s-0044-1779510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
Pediatric wrist injuries pose unique diagnostic challenges due to distinct bone characteristics in children and their diverse injury patterns. The dynamic development of the wrist, marked by changes in bone age and emerging ossification centers, is crucial to evaluate growth and identify potential pathologies. The skeletal composition, rich in cartilage, renders bones relatively weaker yet more elastic, impacting their susceptibility to fracture. Forearm fractures display diverse patterns influenced by torsional forces. Scaphoid fractures, less common in children, differ from those in adults. Conditions like Madelung's deformity and ulnar variance are more common wrist disorders in the pediatric population. In addition, the scarcity and nonspecificity of symptoms in those with tendon injuries and triangular fibrocartilage complex lesions can be diagnostically challenging. This article reviews pediatric wrist injuries, emphasizing ossification patterns, common fracture types, and developmental variants. Grasping these complexities in pediatric wrist development and associated pathologies is essential for precise diagnosis and treatment.
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Affiliation(s)
- Tatiane Cantarelli Rodrigues
- Department of Radiology, Hospital do Coração (HCor), São Paulo, São Paulo, Brazil
- ALTA Diagnostic Center (DASA Group), São Paulo, São Paulo, Brazil
| | - Ivan Rodrigues Barros Godoy
- Department of Radiology, Hospital do Coração (HCor), São Paulo, São Paulo, Brazil
- ALTA Diagnostic Center (DASA Group), São Paulo, São Paulo, Brazil
- Department of Diagnostic Imaging, Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brazil
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Paul SP, Heaton PA. Physiological periosteal thickening in the long bones may mimic non-accidental injury. Br J Hosp Med (Lond) 2021; 82:1. [PMID: 34817259 DOI: 10.12968/hmed.2021.0234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Siba P Paul
- Department of Paediatrics, Yeovil District Hospital, Yeovil, UK
| | - Paul A Heaton
- Department of Paediatrics, Yeovil District Hospital, Yeovil, UK
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Linear lucency of the skull vault: Fracture or accessory skull suture. Leg Med (Tokyo) 2021; 54:101971. [PMID: 34656422 DOI: 10.1016/j.legalmed.2021.101971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/22/2021] [Accepted: 09/28/2021] [Indexed: 11/22/2022]
Abstract
Sutures are a type of fibrous joint that occur only in the skull. However, partial or complete division of bones resulting in anomalous or accessory skull sutures may be misinterpreted as fractures when identified on radiological examination. Thus, it is of paramount clinical and medicolegal importance that these sutures be differentiated from actual fractures which can lead to severe consequences such as false accusation and mis-management of patient. It must be remembered though that the diagnosis in such cases is not straight forward even during postmortem examination which requires careful evaluation of findings with the aid of histology examination and radiology imaging. We present a case of a mis-diagnosis of an anomalous parietal suture in a three-month-old infant.
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Paul SP, Heaton PA. Humeral nutrient artery may mimic non-accidental injury. Br J Hosp Med (Lond) 2021; 82:1-2. [PMID: 33792396 DOI: 10.12968/hmed.2020.0533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Siba P Paul
- Department of Paediatrics, Yeovil District Hospital, Yeovil, UK
| | - Paul A Heaton
- Department of Paediatrics, Yeovil District Hospital, Yeovil, UK
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Paddock M, Adamsbaum C, Barber I, Raissaki M, van Rijn R, Offiah AC. European Society of Paediatric Radiology (ESPR) Child Abuse Taskforce Committee: a response to Miller et al. J Pediatr Endocrinol Metab 2020; 33:941-944. [PMID: 32598317 DOI: 10.1515/jpem-2020-0184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/23/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Michael Paddock
- Medical Imaging Department, Barnsley Hospital NHS Foundation Trust, Gawber Road, Barnsley, UK.,Academic Unit of Child Health, University of Sheffield, Damer Street Building, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, UK
| | - Catherine Adamsbaum
- Pediatric Radiology Department, Paris-Sud University, Faculty of Medicine, and AP-HP, Bicêtre Hospital, Le Kremlin Bicêtre, Paris, France
| | - Ignasi Barber
- Pediatric Radiology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Maria Raissaki
- Radiology Department, University Hospital of Heraklion, University of Crete, Crete, Greece
| | - Rick van Rijn
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Amaka C Offiah
- Academic Unit of Child Health, University of Sheffield, Damer Street Building, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, UK.,Department of Radiology, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, UK
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Karmazyn B, Marine MB, Wanner MR, Delaney LR, Cooper ML, Shold AJ, Jennings SG, Hibbard RA. Accuracy of ultrasound in the diagnosis of classic metaphyseal lesions using radiographs as the gold standard. Pediatr Radiol 2020; 50:1123-1130. [PMID: 32424612 DOI: 10.1007/s00247-020-04671-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/10/2020] [Accepted: 03/31/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Diagnosis of classic metaphyseal lesions (CMLs) in children suspected for child abuse can be challenging. Ultrasound (US) can potentially help diagnose CMLs. However, its accuracy is unknown. OBJECTIVE To evaluate the accuracy of US in the diagnosis of CMLs using skeletal survey reports as the gold standard. MATERIALS AND METHODS US of the metaphysis was performed in three patient groups age <1 year. Informed consent was obtained for patients scheduled for renal US (Group 1) and for patients scheduled for skeletal surveys for possible child abuse (Group 2). Targeted US was also performed in selected patients to evaluate for possible CML suspected on radiographs (Group 3). In Groups 1 and 2, US was performed of both distal femurs, and of either the right or left proximal and distal tibia. Two radiologists (Rad1 and Rad2) independently reviewed the US studies, blinded to history and other imaging. US sensitivity and specificity were calculated using the following gold standards: CML definitely seen on skeletal survey (positive), CML definitely not seen on skeletal survey or part of renal US group (negative). Cases where the skeletal survey was indeterminate for CML were excluded. Kappa statistics were used to evaluate interobserver variability. RESULTS Two hundred forty-one metaphyseal sites were evaluated by US in 63 children (mean age: 5 months; 33 males); 34 had skeletal surveys and 29 had renal US. Kappa for the presence of CML was 0.70 with 95.7% agreement. US sensitivity was 55.0% and 63.2% and the specificity was 97.7% and 96.7% for Rad1 and Rad2, respectively. CONCLUSION US has low sensitivity and high specificity in CML diagnosis. Thus, negative US does not exclude CML, but when the radiographs are equivocal, positive US can help substantiate the diagnosis.
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Affiliation(s)
- Boaz Karmazyn
- Department of Radiology and Imaging Sciences, Riley Hospital for Children, 705 Riley Hospital Dr., Indianapolis, IN, 46202, USA.
| | - Megan B Marine
- Department of Radiology and Imaging Sciences, Riley Hospital for Children, 705 Riley Hospital Dr., Indianapolis, IN, 46202, USA
| | - Matthew R Wanner
- Department of Radiology and Imaging Sciences, Riley Hospital for Children, 705 Riley Hospital Dr., Indianapolis, IN, 46202, USA
| | - Lisa R Delaney
- Department of Radiology and Imaging Sciences, Riley Hospital for Children, 705 Riley Hospital Dr., Indianapolis, IN, 46202, USA
| | - Matthew L Cooper
- Department of Radiology and Imaging Sciences, Riley Hospital for Children, 705 Riley Hospital Dr., Indianapolis, IN, 46202, USA
| | - Andrew J Shold
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - S Gregory Jennings
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Roberta A Hibbard
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
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Eide P, Djuve Å, Myklebust R, Forseth KF, Nøttveit A, Brudvik C, Rosendahl K. Prevalence of metaphyseal injury and its mimickers in otherwise healthy children under two years of age. Pediatr Radiol 2019; 49:1051-1055. [PMID: 31143984 DOI: 10.1007/s00247-019-04413-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/04/2019] [Accepted: 04/12/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Metaphyseal lesions in infants and toddlers are believed to have a high specificity for inflicted injury. OBJECTIVES To examine the prevalence of metaphyseal injury and its mimickers in otherwise healthy children younger than 2 years of age. MATERIALS AND METHODS During 2010-2015, all children 2 years old and younger seen at the Accident and Emergency (A&E) Department due to an injury who had radiographs taken were included. Information on mechanism and clinical findings were drawn from the medical notes. All radiographs were reviewed by two of five researchers together with an experienced paediatric radiologist, registering fracture site and type, and metaphyseal appearances. RESULTS Four hundred and eight children (212 boys) (mean age: 17.7 months, range: 3-24 months) were included, of whom 149 (77 boys) had a total of 162 fractures (incidence of 5.4 per 1,000 children). Only one metaphyseal lesion, without a history of trauma, was seen. Of the 860 metaphyses analysed, 140 (16.3%) were defined as either irregular (74/860, 8.6%) or as having a metaphyseal collar (66/860, 7.7%). Sixty-four of the 66 collars (97.0%) and 54/104 irregularities (60.8%) were located around the wrist and the ankle, while 25/74 irregularities (33.8%) were found around the knee joint. CONCLUSION Metaphyseal lesions with a history of trauma did not occur in otherwise healthy neonates and infants younger than 2 years of age, indicating that this type of fracture has a particular trauma mechanism. Metaphyseal irregularities/collars are frequently seen and should not be mistaken for a classic metaphyseal lesion.
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Affiliation(s)
- Pernille Eide
- Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Åsmund Djuve
- Faculty of Medicine, University of Bergen, Bergen, Norway
| | | | | | | | - Christina Brudvik
- Bergen Accident and Emergency Department, Bergen, Norway
- Department of Clinical Medicine, K1, University of Bergen, Bergen, Norway
| | - Karen Rosendahl
- Department of Clinical Medicine, K1, University of Bergen, Bergen, Norway.
- Section of Paediatric Radiology, Haukeland University Hospital, N-5021, Bergen, Norway.
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Non-metric traits and anatomical variants that can mimic trauma in the human skeleton. Forensic Sci Int 2019; 301:202-224. [PMID: 31176138 DOI: 10.1016/j.forsciint.2019.05.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 05/15/2019] [Accepted: 05/19/2019] [Indexed: 11/21/2022]
Abstract
This paper presents some of the more commonly encountered non-metric traits and minor anatomical variants in the adult human skeleton that can mimic or be mistaken for trauma. Distinguishing non-metric traits is contingent upon both a knowledge of potential non-metric traits as well as the normal developmental timing, location, and anatomy of maturational markers in the human skeleton. Distinguishing non-metric traits from trauma in dry bone is an essential component in establishing an accurate and thorough forensic analysis of human remains, especially as it deals with antemortem and perimortem trauma, and postmortem damage.
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The added value of a second read by pediatric radiologists for outside skeletal surveys. Pediatr Radiol 2019; 49:203-209. [PMID: 30367201 DOI: 10.1007/s00247-018-4276-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/28/2018] [Accepted: 10/02/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Fractures are the second most common finding in non-accidental trauma after cutaneous signs. Interpreting skeletal surveys could be challenging as some fractures are subtle and due to anatomical variations that can mimic injuries. OBJECTIVE To determine the effect of a second read by a pediatric radiologist of skeletal surveys for suspected non-accidental trauma initially read at referring hospitals by general radiologists. MATERIALS AND METHODS In 2016 and 2017, we identified all patients referred to our children's hospital with previous surveys performed and read at a community hospital by an outside radiologist. We excluded patients older than 3 years and studies performed at a children's hospital. The surveys were reviewed by a pediatric radiologist with the printed outside report available. Surveys with disagreement between outside read and pediatric radiologist read were reviewed by a second pediatric radiologist. A disagreement in the second read included only definite discrepant findings agreed upon by both pediatric radiologists. The Fisher exact test was performed to compare the ratio of discrepancies between readers in normal and abnormal surveys. RESULTS Two hundred twenty-five surveys were performed (120 male) at 62 referring hospitals, with a mean patient age of 10.5 months (range: 5 days-3 years). The outside read identified fractures in 104/225 (46.2%) surveys. Thirty-seven of the 225 (16.4%) contained discrepancies in interpretation (n=111). Most of these disagreements (29/37, 78.4%) resulted in a significant change in the report. There was a significant (P<0.0001) difference between disagreement rate in outside read negative (4/111, 3.2%) and positive surveys (34/104, 31.7%). The second read identified additional fractures in 22/225 (9.8%) of the surveys and disagreed with first-read fractures in 17/256 (7.6%). Four of 19 (21.1%) classic metaphyseal lesions diagnosed by the outside read were normal variants; 18 classic metaphyseal lesions were missed by the outside read. CONCLUSIONS This study supports second reads by pediatric radiologists of skeletal surveys for non-accidental trauma.
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Wootton-Gorges SL, Soares BP, Alazraki AL, Anupindi SA, Blount JP, Booth TN, Dempsey ME, Falcone RA, Hayes LL, Kulkarni AV, Partap S, Rigsby CK, Ryan ME, Safdar NM, Trout AT, Widmann RF, Karmazyn BK, Palasis S. ACR Appropriateness Criteria ® Suspected Physical Abuse—Child. J Am Coll Radiol 2017; 14:S338-S349. [DOI: 10.1016/j.jacr.2017.01.036] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 10/19/2022]
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Paddock M, Sprigg A, Offiah A. Imaging and reporting considerations for suspected physical abuse (non-accidental injury) in infants and young children. Part 2: axial skeleton and differential diagnoses. Clin Radiol 2017; 72:189-201. [DOI: 10.1016/j.crad.2016.11.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 11/08/2016] [Accepted: 11/21/2016] [Indexed: 11/16/2022]
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Imaging and reporting considerations for suspected physical abuse (non-accidental injury) in infants and young children. Part 1: initial considerations and appendicular skeleton. Clin Radiol 2017; 72:179-188. [DOI: 10.1016/j.crad.2016.11.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 10/25/2016] [Accepted: 11/07/2016] [Indexed: 11/21/2022]
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The classic metaphyseal lesion and traumatic injury. Pediatr Radiol 2016; 46:1128-33. [PMID: 26902299 DOI: 10.1007/s00247-016-3568-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 12/20/2015] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND It is widely accepted that the classic metaphyseal lesion (CML) is a traumatic lesion, strongly associated with abuse in infants. Nevertheless, various non-traumatic origins for CMLs continue to be suggested in medical and legal settings. No studies to date systematically describe the association of CMLs with other traumatic injuries. OBJECTIVE The primary objective of this study is to examine the association of CMLs with other traumatic injuries in a large data set of children evaluated for physical abuse. MATERIALS AND METHODS This was a retrospectively planned secondary analysis of data from a prospective, observational study of children <120 months of age who underwent evaluation by a child abuse physician. For this secondary analysis, we identified all children ≤12 months of age with an identified CML and determined the number and type of additional injuries identified. Descriptive analysis was used to report frequency of additional traumatic injuries. RESULTS Among 2,890 subjects, 119 (4.1%) were identified as having a CML. Of these, 100 (84.0%) had at least one additional (non-CML) fracture. Thirty-three (27.7%) had traumatic brain injury. Nearly half (43.7%) of children had cutaneous injuries. Oropharyngeal injuries were found in 12 (10.1%) children. Abdominal/thoracic injuries were also found in 12 (10.1%) children. In all, 95.8% of children with a CML had at least one additional injury; one in four children had three or more categories of injury. CONCLUSION CMLs identified in young children are strongly associated with traumatic injuries. Identification of a CML in a young child should prompt a thorough evaluation for physical abuse.
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Delgado Álvarez I, de la Torre IBM, Vázquez Méndez É. The radiologist's role in child abuse: imaging protocol and differential diagnosis. RADIOLOGIA 2016; 58 Suppl 2:119-28. [PMID: 27091551 DOI: 10.1016/j.rx.2016.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 02/25/2016] [Accepted: 02/29/2016] [Indexed: 11/19/2022]
Abstract
Child abuse or nonaccidental trauma is a major problem worldwide; in Spain, there are about 12,000 victims per year. The detection of specific lesions or findings that are incongruent with the reported mechanism of trauma mean that radiologists are often the physician responsible for sounding the alarm in cases of abuse. The triad consisting of subdural hematoma, metaphyseal fracture, and posterior rib fractures is very characteristic of the battered child syndrome. The finding of acute and chronic lesions in the same patient is highly specific for nonaccidental trauma. Fractures of long bones in patients who have yet begun to walk should also alert to possible child abuse. Lesions that are highly specific for abuse, such as classic metaphyseal fractures or posterior rib fractures, can be difficult to demonstrate radiographically and are usually clinically occult. The American College of Radiology (ACR) protocols recommend obtaining three separate X-rays of each upper and lower limb. It is important to use X-ray systems that give high resolution images with low kilovoltage (50-70 kvp) and appropriate milliamperage. A skeletal survey consisting of a series of images collimated to each body region is recommended for all children under the age of two years in whom abuse is suspected. A follow-up skeletal survey about two weeks after the initial survey is useful for detecting new fractures and for assessing the consolidation of others, which helps in dating the lesions. Head injuries are the leading cause of death in abused children. Although computed tomography is the first neuroimaging technique in nonaccidental trauma, magnetic resonance imaging of the head can better characterize the lesions seen on computed tomography and can help to estimate the age of the lesions.
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Affiliation(s)
- I Delgado Álvarez
- Departamento de Radiología Pediátrica, Hospital Universitario Materno Infantil Vall d'Hebron, Barcelona, España.
| | | | - É Vázquez Méndez
- Departamento de Radiología Pediátrica, Hospital Universitario Materno Infantil Vall d'Hebron, Barcelona, España
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Oestreich AE. Concave distal end of ulna metaphysis alone is not a sign of rickets. Pediatr Radiol 2015; 45:998-1000. [PMID: 25638244 DOI: 10.1007/s00247-014-3268-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 11/12/2014] [Accepted: 12/19/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Statements have been made in the literature and in legal testimony that misrepresent the radiographic finding of concave distal end of the ulnar metaphysis. OBJECTIVE To demonstrate that a concave distal end of the ossified ulna in infancy can be normal. MATERIALS AND METHODS Eighty distal wrists of randomly selected infants in the first year of life with radiographic evidence that ruled out rickets were reviewed. RESULTS In 16 of the cases (20%), mild or moderate concavity of the distal end of the ulna was seen. An intact metaphyseal collar of distal radius or ulna confirmed the absence of radiographic rickets. CONCLUSION The finding of 20% of concave distal ulnas in the first year of life confirms the widely acknowledged statements that concave distal end of the ulna alone is not indicative of rickets. Statements to the contrary are not justified.
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Affiliation(s)
- Alan E Oestreich
- Department of Radiology, 5031, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229-3039, USA,
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The metaphyseal collar is also present until later childhood and at birth. Pediatr Radiol 2014; 44:1046-7. [PMID: 24898395 DOI: 10.1007/s00247-014-3034-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 05/06/2014] [Indexed: 10/25/2022]
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