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Ina J, Dumaine AM, Flanagan C, Haase L, Moore R, Rimnac C, Gilmore A. Findings Associated With Nonaccidental Trauma in Children With Isolated Femoral Diaphyseal Fractures. J Pediatr Orthop 2024; 44:e717-e721. [PMID: 38813812 DOI: 10.1097/bpo.0000000000002740] [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] [Indexed: 05/31/2024]
Abstract
BACKGROUND Pediatric patients with isolated femoral diaphyseal fractures are difficult to assess for nonaccidental trauma (NAT). The purpose of this study was to determine (1) if there are any demographic features of isolated femoral diaphyseal fractures associated with suspected NAT and (2) if there are clinical signs associated with isolated femoral diaphyseal fractures associated with suspected NAT. METHODS All patients with femoral diaphyseal fractures from January 2010 to June 2018 were reviewed. We included patients younger than 4 years old with isolated femoral diaphyseal fractures. We excluded patients 4 years old and older, polytraumas, motor vehicle collisions, and patients with altered bone biology. Diagnosis of suspected NAT was determined by review of a documented social work assessment. We recorded fracture characteristics including location along femur as well as fracture pattern and presence of associated findings on NAT workup including the presence of retinal hemorrhage, subdural hematoma, evidence of prior fracture, or cutaneous lesions. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of these associated findings were calculated. RESULTS Totally, 144 patients met the inclusion criteria. Social work was consulted on 50 patients (35%). Suspected NAT was diagnosed in 27 patients (19%). The average age of patients with suspected NAT was 0.82 and 2.25 years in patients without NAT ( P <0.01). The rate and type of skin lesions present on exam were not different between the 2 groups. Patients with suspected NAT had no findings of retinal hemorrhage or subdural hematoma, but 5 of 27 patients (19%) had evidence of prior fracture on skeletal survey. The sensitivities of retinal hemorrhage, subdural, and skeletal survey were 0%, 0%, and 19% and the specificities of all were 100%. The NPVs were 39%, 27%, and 63%, respectively. The PPV of skeletal survey was 100%. Since there were no patients in this study with positive findings of retinal hemorrhage or subdural hematoma, the PPV for these could not be assessed. CONCLUSIONS In the current study, signs of NAT such as skin lesions, retinal hemorrhage, subdural hematoma, and evidence of prior fracture on skeletal survey may not be helpful to diagnosis suspected NAT in patients with an isolated femoral diaphyseal fracture. LEVEL OF EVIDENCE Level III-diagnostic study.
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Affiliation(s)
- Jason Ina
- Department of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital at University Hospitals Cleveland Medical Center
| | - Anne M Dumaine
- Department of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital at University Hospitals Cleveland Medical Center
| | - Christopher Flanagan
- Department of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital at University Hospitals Cleveland Medical Center
| | - Lucas Haase
- Department of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital at University Hospitals Cleveland Medical Center
| | - Rebecca Moore
- Department of Mechanical and Aerospace Engineering, Case Western Reserve University, Cleveland, OH
| | - Clare Rimnac
- Department of Mechanical and Aerospace Engineering, Case Western Reserve University, Cleveland, OH
| | - Allison Gilmore
- Department of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital at University Hospitals Cleveland Medical Center
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Jain D, Le L, Kissoon N. Ophthalmologic findings in abusive head trauma. Semin Pediatr Neurol 2024; 50:101141. [PMID: 38964817 DOI: 10.1016/j.spen.2024.101141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/20/2024] [Accepted: 05/07/2024] [Indexed: 07/06/2024]
Abstract
A leading cause of death and disability in infancy is abusive head trauma (AHT) and there are common clinical signs that help to establish this diagnosis. Children diagnosed with AHT can have many ophthalmologic findings, including retinal hemorrhages, retinoschisis, subconjunctival hemorrhages, corneal injury, and globe rupture. If any such injuries are suspected, an ophthalmologic consultation, with indirect ophthalmoscopy, should be completed. In addition to a complete physical exam, a thorough history imaging, and lab work, should be obtained to investigate the etiology of ophthalmic pathology including accidental and systemic causes. In general, studies show that retinal hemorrhages that are multilayered, too numerous to count, and located from the posterior pole to the ora serrata are highly suspicious for abusive head trauma.
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Affiliation(s)
- Disha Jain
- Baylor College of Medicine, 6701 Fannin St., 17th Floor, Houston, TX 77030, United States.
| | - Lien Le
- Baylor College of Medicine, 6701 Fannin St., 17th Floor, Houston, TX 77030, United States
| | - Natalie Kissoon
- University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7821, San Antonio, TX 78229, United States
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Hymel KP, Boos SC, Armijo-Garcia V, Musick M, Weeks K, Haney SB, Marinello M, Herman BE, Frazier TN, Carroll CL, Even K, Wang M. An analysis of physicians' diagnostic reasoning regarding pediatric abusive head trauma. CHILD ABUSE & NEGLECT 2022; 129:105666. [PMID: 35567958 PMCID: PMC10724711 DOI: 10.1016/j.chiabu.2022.105666] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 04/26/2022] [Accepted: 05/04/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Physician diagnoses of abusive head trauma (AHT) have been criticized for circular reasoning and over-reliance on a "triad" of findings. Absent a gold standard, analyses that apply restrictive reference standards for AHT and non-AHT could serve to confirm or refute these criticisms. OBJECTIVES To compare clinical presentations and injuries in patients with witnessed/admitted AHT vs. witnessed non-AHT, and with witnessed/admitted AHT vs. physician diagnosed AHT not witnessed/admitted. To measure the triad's AHT test performance in patients with witnessed/admitted AHT vs. witnessed non-AHT. PARTICIPANTS AND SETTING Acutely head injured patients <3 years hospitalized for intensive care across 18 sites between 2010 and 2021. METHODS Secondary analyses of existing, combined, cross-sectional datasets. Probability values and odds ratios were used to identify and characterize differences. Test performance measures included sensitivity, specificity, and predictive values. RESULTS Compared to patients with witnessed non-AHT (n = 100), patients with witnessed/admitted AHT (n = 58) presented more frequently with respiratory compromise (OR 2.94, 95% CI: 1.50-5.75); prolonged encephalopathy (OR 5.23, 95% CI: 2.51-10.89); torso, ear, or neck bruising (OR 11.87, 95% CI: 4.48-31.48); bilateral subdural hemorrhages (OR 8.21, 95% CI: 3.94-17.13); diffuse brain hypoxia, ischemia, or swelling (OR 6.51, 95% CI: 3.06-13.02); and dense, extensive retinal hemorrhages (OR 7.59, 95% CI: 2.85-20.25). All differences were statistically significant (p ≤ .001). No significant differences were observed in patients with witnessed/admitted AHT (n = 58) vs. patients diagnosed with AHT not witnessed/admitted (n = 438). The triad demonstrated AHT specificity and positive predictive value ≥0.96. CONCLUSIONS The observed differences in patients with witnessed/admitted AHT vs. witnessed non-AHT substantiate prior reports. The complete absence of differences in patients with witnessed/admitted AHT vs. physician diagnosed AHT not witnessed/admitted supports an impression that physicians apply diagnostic reasoning informed by knowledge of previously reported injury patterns. Concern for abuse is justified in patients who present with "the triad."
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Affiliation(s)
- Kent P Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA.
| | - Stephen C Boos
- Department of Pediatrics, UMass Chan Medical School-Baystate Health, 759 Chestnut Street, Springfield, MA 01199, USA.
| | - Veronica Armijo-Garcia
- University of Texas Health Sciences Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
| | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, USA.
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, 3243 East Murdoch, Wichita, KS 67208, USA
| | - Suzanne B Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, 8200 Dodge Street, Omaha, NE 68114, USA.
| | - Mark Marinello
- Department of Pediatrics, Children's Hospital of Richmond at VCU, 1250 East Marshall Street, Richmond, VA 23219, USA.
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, 100 North Mario Capecchie Drive, Salt Lake City, UT 84113, USA.
| | - Terra N Frazier
- Department of Pediatrics, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | - Christopher L Carroll
- Department of Pediatrics, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT 06106, USA.
| | - Katelyn Even
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA.
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA 17033, USA.
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Caré MM. Parenchymal Insults in Abuse—A Potential Key to Diagnosis. Diagnostics (Basel) 2022; 12:diagnostics12040955. [PMID: 35454003 PMCID: PMC9029348 DOI: 10.3390/diagnostics12040955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/30/2022] [Accepted: 04/08/2022] [Indexed: 02/01/2023] Open
Abstract
Subdural hemorrhage is a key imaging finding in cases of abusive head trauma and one that many radiologists and radiology trainees become familiar with during their years of training. Although it may prove to be a marker of trauma in a young child or infant that presents without a history of injury, the parenchymal insults in these young patients more often lead to the debilitating and sometimes devastating outcomes observed in this young population. It is important to recognize these patterns of parenchymal injuries and how they may differ from the imaging findings in other cases of traumatic injury in young children. In addition, these parenchymal insults may serve as another significant, distinguishing feature when making the medical diagnosis of abusive head injury while still considering alternative diagnoses, including accidental injury. Therefore, as radiologists, we must strive to look beyond the potential cranial injury or subdural hemorrhage for the sometimes more subtle but significant parenchymal insults in abuse.
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Affiliation(s)
- Marguerite M. Caré
- Department of Radiology and Medical Imaging, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
- Department of Radiology and Medical Imaging, University of Cincinnati, Cincinnati, OH 45267, USA
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Weiss R, He CH, Khan S, Parsikia A, Mbekeani JN. Ocular Injuries in Pediatric Patients Admitted With Abusive Head Trauma. Pediatr Neurol 2022; 127:11-18. [PMID: 34922138 DOI: 10.1016/j.pediatrneurol.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pediatric abusive head trauma (AHT) refers to head injury from intentional blunt force or violent shaking in children aged five years or less. We sought to evaluate the epidemiology of ocular injuries in AHT. METHODS This retrospective analysis of the National Trauma Data Bank (2008 to 2014) identified children aged five years or less with AHT and ocular injuries using ICD-9-CM codes. Demographic data, types of ocular and nonocular/head injuries, geographic location, length of hospital admission, injury severity, and Glasgow Coma scores were tabulated and analyzed. RESULTS A total of 10,545 children were admitted with AHT, and 2550 (24.2%) had associated ocular injuries; 58.7% were female. The mean age was 0.5 (±1.0) years. Most (85.7%) were aged one year or less. Common ocular injuries included contusion of eye/adnexa (73.7%) and retinal edema (59.3%), and common head injuries were subdural hemorrhage (SDH) (72.8%) and subarachnoid hemorrhage (22.9%). Retinal hemorrhages occurred in 5.3%. About 42.8% of children had injury severity scores greater than 24 (very severe), and the mortality rate was 19.2%. Children aged one year or less had the greatest odds of retinal hemorrhages (odds ratio [OR] = 2.44; P = 0.008) and SDH (OR = 1.55; P < 0.001), and the two- to three-year-old group had the greatest odds of contusions (OR = 1.68; P = 0.001), intracerebral hemorrhages (OR = 1.55; P = 0.002), and mortality (OR = 1.78; P < 0.001). For all ages, SDH occurred most frequently with retinal edema compared with other ocular injuries (OR = 2.25; P < 0.001). CONCLUSIONS AND RELEVANCE Ocular injuries varied with age and were variably associated with nonocular injury. The youngest group was most frequently affected; however, the two- to three-year-old group was most likely to succumb to injuries.
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Affiliation(s)
- Rebecca Weiss
- Department of Ophthalmology & Visual Sciences, Montefiore Medical Center, Bronx, New York; Albert Einstein College of Medicine, Bronx, New York
| | | | - Sabine Khan
- Department of Ophthalmology & Visual Sciences, Montefiore Medical Center, Bronx, New York; Albert Einstein College of Medicine, Bronx, New York
| | - Afshin Parsikia
- Department of Surgery (Trauma), Jacobi Medical Center, Bronx, New York; Research Services, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce N Mbekeani
- Albert Einstein College of Medicine, Bronx, New York; Department of Surgery (Ophthalmology), Jacobi Medical Center, Bronx, New York.
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Boos SC, Wang M, Karst WA, Hymel KP. Traumatic Head Injury and the Diagnosis of Abuse: A Cluster Analysis. Pediatrics 2022; 149:183816. [PMID: 34890450 PMCID: PMC9645685 DOI: 10.1542/peds.2021-051742] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Data guiding abusive head trauma (AHT) diagnosis rest on case-control studies that have been criticized for circularity. We wished to sort children with neurologic injury using mathematical algorithms, without reference to physicians' diagnoses or predetermined diagnostic criteria, and to compare the results to existing AHT data, physicians' diagnoses, and a proposed triad of findings. METHODS Unsupervised cluster analysis of an existing data set regarding 500 young patients with acute head injury hospitalized for intensive care. Three cluster algorithms were used to sort (partition) patients into subpopulations (clusters) on the basis of 32 reliable (κ > 0.6) clinical and radiologic variables. P values and odds ratios (ORs) identified variables most predictive of partitioning. RESULTS The full cohort partitioned into 2 clusters. Variables substantially (P < .001 and OR > 10 in all 3 cluster algorithms) more prevalent in cluster 1 were imaging indications of brain hypoxemia, ischemia, and/or swelling; acute encephalopathy, particularly when lasting >24 hours; respiratory compromise; subdural hemorrhage or fluid collection; and ophthalmologist-confirmed retinoschisis. Variables substantially (P < .001 and OR < 0.10 in any cluster algorithm) more prevalent in cluster 2 were linear parietal skull fracture and epidural hematoma. Postpartitioning analysis revealed that cluster 1 had a high prevalence of physician-diagnosed abuse. CONCLUSIONS Three cluster algorithms partitioned the population into 2 clusters without reference to predetermined diagnostic criteria or clinical opinion about the nature of AHT. Clinical difference between clusters replicated differences previously described in comparisons of AHT with non-AHT. Algorithmic partition was predictive of physician diagnosis and of the triad of findings heavily discussed in AHT literature.
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Affiliation(s)
- Stephen C. Boos
- Department of Pediatrics, University of Massachusetts Chan Medical School—Baystate, Baystate Medical Center, Springfield, Massachusetts,Address correspondence to Stephen C. Boos, MD, Baystate Medical Center, Family Advocacy Center, 300 Carew St, Springfield, MA 01199. E-mail:
| | - Ming Wang
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Wouter A. Karst
- Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, Netherlands
| | - Kent P. Hymel
- Department of Pediatrics, College of Medicine, Pennsylvania State University and Penn State Health Children’s Hospital, Hershey, Pennsylvania
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Maiese A, Iannaccone F, Scatena A, Del Fante Z, Oliva A, Frati P, Fineschi V. Pediatric Abusive Head Trauma: A Systematic Review. Diagnostics (Basel) 2021; 11:diagnostics11040734. [PMID: 33924220 PMCID: PMC8074611 DOI: 10.3390/diagnostics11040734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 02/03/2023] Open
Abstract
Abusive head trauma (AHT) represents a commonly misdiagnosed condition. In fact, there is no pathognomonic sign that allows the diagnosis in children. Therefore, it is such an important medico-legal challenge to evaluate reliable diagnostic tools. The aim of this review is to evaluate the current scientific evidence to assess what the best practice is in order to diagnose AHT. We have focused particularly on evaluating the importance of circumstantial evidence, clinical history, the use of postmortem radiological examinations (such as CT and MRI), and the performance of the autopsy. After autopsy, histological examination of the eye and brain play an important role, with attention paid to correlation with symptoms found in vivo.
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Affiliation(s)
- Aniello Maiese
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (A.M.); (F.I.); (A.S.)
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli, Italy;
| | - Francesca Iannaccone
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (A.M.); (F.I.); (A.S.)
| | - Andrea Scatena
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (A.M.); (F.I.); (A.S.)
| | - Zoe Del Fante
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy;
| | - Antonio Oliva
- Department of Health Surveillance and Bioethics, Section of Legal Medicine, Catholic University, Fondazione Policlinico A. Gemelli IRCCS, 00100 Rome, Italy;
| | - Paola Frati
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli, Italy;
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy;
| | - Vittorio Fineschi
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli, Italy;
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy;
- Correspondence: ; Tel.: +39-064-991-2722
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Suh DW, Song HH, Mozafari H, Thoreson WB. Determining the Tractional Forces on Vitreoretinal Interface Using a Computer Simulation Model in Abusive Head Trauma. Am J Ophthalmol 2021; 223:396-404. [PMID: 32663454 DOI: 10.1016/j.ajo.2020.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 06/13/2020] [Accepted: 06/16/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Abusive head trauma (AHT) is the leading cause of infant death and long-term morbidity from injury. The ocular consequences of AHT are controversial, and the pathophysiology of retinal research findings is still not clearly understood. It has been postulated that vitreoretinal traction plays a major role in the retinal findings. A computer simulation model was developed to evaluate the vitreoretinal traction and determine whether the distribution of forces in different layers and locations of the retina can explain the patterns of retinal hemorrhage (RH) seen in AHT. DESIGN Computer simulation model study. METHODS A computer simulation model of the pediatric eye was developed to evaluate preretinal, intraretinal, and subretinal stresses during repetitive shaking. This model was also used to examine the forces applied to various segments along blood vessels. RESULTS Calculated stress values from the computer simulation ranged from 3-16 kPa at the vitreoretinal interface through a cycle of shaking. Maximal stress was observed at the periphery of the retina, corresponding to areas of multiple vessel bifurcations, followed by the posterior pole of the retina. Stress values were similar throughout all 3 layers of the retina (preretinal, intraretinal, and subretinal layers). CONCLUSIONS Ocular manifestations from AHT revealed unique retinal characteristics. The model predicted stress patterns consistent with the diffuse retinal hemorrhages (RH) typically found in the posterior pole and around the peripheral retina in AHT. This computer model demonstrated that similar stress forces were produced in different layers of the retina, consistent with the finding that retinal hemorrhages are often found in multiple layers of the retina. These data can help explain the RH patterns commonly found in AHT.
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Pediatric Nonaccidental Trauma: Experience at a Level 1 Trauma Center. Int J Pediatr 2020; 2020:6621992. [PMID: 33456474 PMCID: PMC7785376 DOI: 10.1155/2020/6621992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/13/2020] [Accepted: 12/15/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Pediatric nonaccidental trauma (NAT) is difficult to diagnose. Several isolated injuries in NAT could happen in the setting of accidental trauma (AT), and having a high index of suspicion is important to correctly identify abuse. NAT has a significant mortality rate if the sentinel event is not adequately diagnosed, and the infant is not separated from the perpetrator. Level 1 pediatric trauma centers (PTC) see a significant number of NAT. We evaluated the injury patterns of NAT admissions at our level 1 PTC. Methods Retrospective analysis of all cases of NAT for children under the age of two admitted at an ACS level 1 pediatric trauma center between the years of 2016 and 2018. Charts were queried for demographic data, injury patterns, mortality, and disposition. Correlation between disposition status and injury patterns was performed. The Fisher Exact test and student t-test were used to study the significance of differences in categorical and continuous data, respectively. Results 32/91 (35%) trauma patients under the age of two years were diagnosed as NAT in the three-year study period. 21/32 (39%) male and 11/26 (42%) female admissions were confirmed NAT (p = NS). 20 were under 1 year of age, and 12 were aged between 1 and 2 years (p = NS). 13 (41%) were Caucasian, 6 (19%) were Hispanic/Latino, 11 (34%) were Black, and 2(6%) were of unknown ethnicity (p = NS). Facial, torso, lower extremity, retinal, and internal organ injury were significantly more common with NAT. Medicaid coverage was noted in 31/32 (97%) NAT patients. 20/32 (62.5%) patients were legally displaced as a result of the NAT. Conclusion 1/3rd of all admissions at a pediatric level 1 trauma center were identified as NAT. A high index of suspicion is necessary to not miss NAT, as injury patterns are variable. Nearly 1/3rd of all victims go back to the same environment where they sustained NAT increasing their susceptibility to future NAT.
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Nonaccidental trauma in pediatric patients: evidence-based screening criteria for ophthalmologic examination. J AAPOS 2020; 24:226.e1-226.e5. [PMID: 32822853 DOI: 10.1016/j.jaapos.2020.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/25/2020] [Accepted: 03/29/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Ophthalmologic examination is included in the work-up for pediatric nonaccidental trauma (NAT) when there is concern for retinal hemorrhage. However, dilated fundus examination entails patient discomfort and prohibition of assessment of pupillary response. Previous studies have suggested that patients without neuroimaging abnormalities are unlikely to have retinal hemorrhage. The purpose of the current study was to analyze the findings in patients who received NAT evaluation with eye examination at our institution, and to propose screening criteria for inclusion of ophthalmologic examination in NAT evaluation. METHODS The medical records of patients who received NAT evaluation with ophthalmologic examination at The Johns Hopkins Children's Center Pediatric Emergency Department from August 2014 to July 2018 were reviewed retrospectively. Data collected included demographics, presenting symptoms, imaging findings, and ophthalmologic examination findings. The main outcome measure was presence of retinal hemorrhage. RESULTS A total of 192 evaluations with ophthalmologic examination were included, representing 190 unique individuals of mean age 8.4 ± 9.5 months at presentation. In approximately half (54%) of the evaluations, there were abnormal findings on neuroimaging. Fifteen children (8%) had retinal hemorrhage, all of whom also had abnormal neuroimaging. Abnormal neuroimaging was associated with presence of retinal hemorrhage, with an odds ratio of 21.0 (95% CI, 3.47-∞; P < 0.001). Of the 15 children with retinal hemorrhage, 14 had subdural hemorrhage. CONCLUSIONS When neuroimaging abnormalities are present, ophthalmologic examination should be performed as part of the pediatric NAT evaluation. When there is no evidence of head injury on neuroimaging, ophthalmologic examination should not be routine.
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