Spine Injuries in Child Abuse

Neuroimaging considerations in abusive head trauma

This focused review on abusive head trauma describes the injuries to the head, brain and/or spine of an infant or young child from inflicted trauma and their neuroimaging correlates. Accurate recognition and diagnosis of abusive head trauma is paramount to prevent repeated injury, provide timely treatment, and ensure that accidental or underlying medical contributors have been considered. In this article, we aim to discuss the various findings on neuroimaging that have been associated with AHT, compared to those that are more consistent with accidental injuries or with underlying medical causes that may also be on the differential.

Reports of Maltreatment in a Children's Hospital: Evaluation of the Epidemiological Profile and Its Relationship with the Outcome in Fractures

Objective  To describe suspected/confirmed cases of child maltreatment related to fractures in a pediatric hospital in southern Brazil. Method  Study of the Information System of Notifiable Diseases notifications and the victims' medical records between January/2016 and December/2020. Variables related to the victim, the perpetrator, the type of abuse, the presence of fractures, and their anatomical location and death were evaluated. Logistic regression was performed to identify fracture-related variables, adjusted for sex and age. The results were expressed in odds ratios and their respective 95% confidence intervals. It was considered significant p  < 0.05. Results  There were 276 cases, 73 infants (26.4%), male predominance (151, 54.7%), with authorship of the mistreatment by relatives (245, 96,0%), 85 (31,5%), they presented fractures, with five deaths (1.9%). Factors related to the presence of fracture: age of the victim (less than two years old; n  = 82; or 2.48; 95% CI: 1.45 - 4.25), having more than two aggressors involved ( n  = 144; or 2.09; 95% CI: 1.16-3.75), the medium being traffic/automobile accident, ( n  = 52; or 2.65; 95% CI: 1.04-6.75), consult an orthopedist ( n  = 91; or 6.77 / 95% CI: 3.66-12.51), and the need for surgical intervention ( n  = 15; OR 36.72; 95% CI: 8.22-164.03). Conclusions  The importance of suspicion, early identification of aggression, and the correct completion of notifications for activating the system of guaranteeing rights and removal of the aggressor was emphasized.

Spinal lesions caused by abusive trauma in young children

BACKGROUND AND PURPOSE

Spinal lesions are increasingly recognized as an integral part of the child abuse spectrum; however, the description of lesions, their biomechanics, true incidence, clinical impact, and medicolegal implications are poorly understood.

MATERIAL AND METHODS

We report from the literature and our personal experience on abusive spinal lesions (ASL) in children under 3 years, compared with cases of abusive head injuries (AHI) without spinal lesions on the one hand and with accidental spinal lesions on the other.

RESULTS

Between 2002 and 2021, we collected 12 observations of ASL, 4 male and 8 female. These were compared with 338 cases of infants having AHI without ASL and 18 cases of accidental spinal trauma in the same age group. Fractures were found in 10 cases of ASL: wedge fracture in 9, and complete disruption with paraplegia in one, which required emergency reduction and stabilization with a good motor recovery. Two patients had intraspinal hemorrhagic lesions without fracture, associated in one case with tetraplegia which contributed to the fatal outcome. ASL affected girls more often and had a more severe clinical presentation; more than half of ASL involved the lumbar levels, which were unaffected in accidental traumas.

CONCLUSIONS

ASL are not exceptional, and their presence corroborates cranial lesions indicating child abuse. Two etiologies emerge from this study: wedge fractures and cervical spinal cord lesions caused by shaking and the rare thoraco-lumbar dislocation indicating a particularly violent assault. Systematic MRI study of the spine is warranted in cases of child abuse.

Pearls and Pitfalls of Thoracic Manifestations of Abuse in Children

Child abuse is a broad term that includes, but is not limited to, physical or emotional harm, neglect, sexual abuse, and exploitation. In 2018 in the United States, there were nearly 700,000 victims of such maltreatment, of which 1700 children died. The majority of deaths occur in infants and toddlers under 3 years of age. While clinical signs and symptoms may raise suspicion for inflicted injury, such as bruising in young infants, imaging often plays a central role in identifying and characterizing nonaccidental trauma. The purpose of this article is to discuss the array of inflicted traumatic injuries to the thorax in children. Rib fractures are among the most common and telling features of physical abuse, especially in infants. The locations of such fractures and differences in appearance while healing will be presented, along with potential mimics and pitfalls. Less typical fractures seen in abuse will also be reviewed, including those of the sternum, clavicle, spine, and scapula. Finally, uncommon injuries to the lungs, heart and esophagus will also be considered.

Incidence and Epidemiology of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

This review aims to search the epidemiology and incidence rates of thoracolumbar spine fractures. A systematic review of the literature of the last 10 years gave 586 results with “incidence,” and 387 results with “epidemiology,” of which 39 papers were analyzed. The review results were discussed and voted in 2 consensus meetings of the WFNS (World Federation of Neurosurgical Societies) Spine Committee. Out of 39 studies, 15 studies have focused on thoracolumbar trauma, remaining 24 studies have looked at all spine trauma. Most were retrospective in nature; few were prospective and multicenter. Some studies have focused on specific injuries. The annual incidence of TL fractures is about 30/100,000 inhabitants including osteoporotic fractures. There is a trend to increase the fractures in elderly population especially in developed countries, while an increase of motor vehicle accidents in developing countries. The mortality rate among male elderly patients is relatively high. The incidence of thoracolumbar spine fractures is increasing because of low-velocity falls in the elderly population. The main reasons are falls and traffic accidents. Learning the regional differences and some special forms of trauma such as extreme sports, war, and gunshot injuries will help the prevention of the thoracolumbar spine fractures.

Child Abuse with Thoracolumbar Fracture-Dislocation Treated with Pedicle Screw Fixation in a 2-Year-Old: A Case Report

CASE

A nonverbal 2-year-old boy presented with acute-on-chronic thoracolumbar fracture-subluxation with associated chylothorax and progressive neurologic dysfunction secondary to nonaccidental trauma. We discussed the successful management of this patient with short-segment pedicle screw instrumentation resulting in complete resolution of his chylothoraxes and neurologic impairment. A clinical follow-up is reported out to 12 months after hardware removal.

CONCLUSION

Thoracolumbar fracture-subluxation with massive chylothorax is a rare and important presentation of nonaccidental trauma that must be recognized. Temporary pedicle screw fixation is a successful treatment option for young children presenting with this difficult spinal pathology.

Racial Disparities in Health Care Resource Utilization After Pediatric Cervical and/or Thoracic Spinal Injuries

OBJECTIVE

This study aimed to investigate the impact of race on hospital length of stay (LOS) and hospital complications among pediatric patients with cervical/thoracic injury.

METHODS

A retrospective cohort was performed using the 2017 admission year from 753 facilities utilizing the National Trauma Data Bank. All pediatric patients with cervical/thoracic spine injuries were identified using the ICD-10-CM diagnosis coding system. These patients were segregated by their race, non-Hispanic white (NHW), non-Hispanic black (NHB), non-Hispanic Asian (NHA), and Hispanic (H). Demographic, hospital variable, hospital complications, and LOS data were collected. A linear and logistic multivariate regression analysis was performed to determine the risk ratio for hospital LOS as well as complication rate, respectively.

RESULTS

A total of 4,125 pediatric patients were identified. NHB cohort had a greater prevalence of cervical-only injuries (NHW: 37.39% vs. NHB: 49.93% vs. NHA: 34.29% vs. H: 38.71%, P < 0.001). While transport accident was most common injury etiology for both cohorts, NHB cohort had a greater prevalence of assault (NHW: 1.53% vs. NHB: 17.40% vs. NHA: 2.86% vs. H: 6.58%, P < 0.001) than the other cohorts. Overall complication rates were significantly higher among NHB patients (NHW: 9.39% vs. NHB: 15.12% vs. NHA: 14.29% vs. H: 13.60%, P < 0.001). Compared with the NHW cohort, NHB, NHA, and H had significantly longer hospital LOS (NHW: 6.15 ± 9.03 days vs. NHB: 9.24 ± 20.78 days vs. NHA: 9.09 ± 13.28 days vs. H: 8.05 ± 11.45 days, P < 0.001). NHB race was identified as a significant predictor of increased LOS on multivariate regression analysis (risk ratio: 1.14, 95% confidence interval: 0.46, 1.82; P = 0.001) but not hospital complications (P = 0.345).

CONCLUSIONS

Race may significantly impact health care resource utilization following pediatric cervical/thoracic spinal trauma.

Nonaccidental Trauma Managed with Open Spinal Fixation and Instrumentation and a Review of the Literature

Nonaccidental trauma (NAT), causing spinal injury is rare and occurs in up to 3% of cases. Management of these injuries is typically conservative, and thus surgical management is not widely reported in the literature. In this case report, we presented three patients to review the effectiveness of spinal instrumentation and posterior fusion in pediatric patients due to NAT. All patients recovered well and were neurologically intact at last follow-up with no postprocedural complications noted. Spinal arthrodesis is a safe, effective way to manage spinal injuries due to NAT in cases of fracture-dislocation, distraction injuries, as well as cases involving neurologic compromise.

Spinal cord injury as an indicator of abuse in forensic assessment of abusive head trauma (AHT)

Abusive head trauma (AHT) in children is notoriously one of the most challenging diagnoses for the forensic pathologist. The pathological “triad”, a combination of intracranial subdural haematoma, cerebral oedema with hypoxic-ischaemic changes and retinal haemorrhages, is frequently argued to be insufficient to support a corroborated verdict of abuse. Data from all available English-language scientific literature involving radiological and neuropathological spinal cord examination is reviewed here in order to assess the contribution of spinal cord changes in differentiating abusive from accidental head trauma. In agreement with the statistically proven association between spinal subdural haemorrhage (SDH) and abuse (Choudhary et al. in Radiology 262:216–223, 2012), spinal blood collection proved to be the most indicative finding related to abusive aetiology. The incidence of spinal blood collection is as much as 44–48% when all the spinal cord levels are analysed as opposed to just 0–18% when the assessment is performed at cervical level only, in agreement with the evidence of the most frequent spinal SDH location at thoracolumbar rather than cervical level. In this review, the source of spinal cord blood collection and how the age of the child relates to the position of spinal cord lesions is also discussed. We concluded that the ante mortem MRI examination and post mortem examination of whole-length spinal cord is of fundamental interest for the assessment of abuse in the forensic setting.

Abusive Pediatric Thoracolumbar Fracture Due to Forced Hyperextension: Case Report, Biomechanical Considerations, and Review of the Literature

Pediatric thoracolumbar fractures are rare due to the physiological differences which afford greater resilience to the immature spine. Most pediatric thoracolumbar fractures occur as the result of high energy trauma, such as motor vehicle accidents, and modes of reasonable accidental injuries are limited by age and developmental capabilities of the child. These fractures can occur as the result of inflicted blunt force trauma and child abuse, and in most cases, the mechanism of injury to the spine is not known. We report the death of a 29-month-old man due to blunt force trauma to the back and forced hyperextension of the thoracolumbar spine causing fracture of the fourth lumbar (L4) vertebral body. A complete forensic examination revealed a previous healing fracture of the anterior aspect of the L4 vertebral body, with acute disruption of the anterior longitudinal ligament overlying the fracture site, complete fracture of the vertebral body, and fatal retroperitoneal hemorrhage. We present a review of the biomechanical considerations of the pediatric spine, a survey of pediatric spinal fractures, and a review of the literature on pediatric abusive thoracolumbar fractures. In this case, there was never a provided explanation for how the injury occurred; however, understanding the biomechanics of the pediatric spine allowed for the determination of the mechanism, force required to produce this specific pattern of abusive spinal injury, and the manner of death.

Septic arthritis of the hip and knee treated surgically in pediatric patients: Analysis of the Kids' Inpatient Database

OBJECTIVE

This study evaluated incidence over time, any association between race and demographics, and hospital-related parameters in pediatric patients with septic hip or knee arthritis.

METHODS

The Kids' Inpatient Database was used to identify all children with a diagnosis of septic hip or knee arthritis who underwent incision and drainage (1997-2012).

RESULTS

Between 1997 and 2012, overall incidence of septic arthritis of the knee (0.20-0.33 per 100,000) and hip (0.12-0.18 per 100,000) increased.

CONCLUSION

Incidence of pediatric septic joint arthritis, an emergent orthopaedic condition, has increased over time. Patient demographics may vary with respect to both age and race.

Retrospondyloptosis of the Spine Secondary to Nonaccidental Trauma

Spinal fracture rates from NAT have been reported in <1-3% of spinal injury cases. We present a 13-month-old female who presented with signs of spinal cord injury and was found to have complete retrospondylolisthesis of T12 vertebra and multiple rib fractures in various stages of healing due to NAT. This case reports an extremely severe spinal injury due to NAT of which there are few in the literature and highlights the importance of suspicion of NAT when pediatric patients present with neurologic symptoms and spinal trauma without plausible mechanism of injury.